Healthcare Provider Details

I. General information

NPI: 1578022166
Provider Name (Legal Business Name): DAEDLY POTUSEK APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2019
Last Update Date: 11/20/2024
Certification Date: 11/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 WHITNEY AVE STE 290
HAMDEN CT
06518-3695
US

IV. Provider business mailing address

2661 WHITNEY AVENUE
HAMDEN CT
06518
US

V. Phone/Fax

Practice location:
  • Phone: 203-903-8308
  • Fax: 203-599-3927
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number8133
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: