Healthcare Provider Details

I. General information

NPI: 1013474261
Provider Name (Legal Business Name): JENNIFER PARK SEVERENKO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/25/2019
Last Update Date: 11/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 HOSPITAL AVE
DANBURY CT
06810-6099
US

IV. Provider business mailing address

24 HOSPITAL AVE
DANBURY CT
06810-6099
US

V. Phone/Fax

Practice location:
  • Phone: 203-739-7118
  • Fax: 203-749-9030
Mailing address:
  • Phone: 203-739-7118
  • Fax: 203-749-9030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number12.008590
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: