Healthcare Provider Details

I. General information

NPI: 1063282853
Provider Name (Legal Business Name): MISS MISHELLE DIANE ANDERSEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2024
Last Update Date: 04/03/2026
Certification Date: 04/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

64 BLACK ROCK AVE
BRIDGEPORT CT
06605-1200
US

IV. Provider business mailing address

64 BLACK ROCK AVE
BRIDGEPORT CT
06605-1200
US

V. Phone/Fax

Practice location:
  • Phone: 203-641-6110
  • Fax:
Mailing address:
  • Phone: 203-641-6110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number7523
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: