Healthcare Provider Details

I. General information

NPI: 1164107421
Provider Name (Legal Business Name): MADISON ALAIA FUCCI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2023
Last Update Date: 07/07/2023
Certification Date: 07/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 DURHAM RD
MADISON CT
06443-1858
US

IV. Provider business mailing address

688 GOOSE LN
GUILFORD CT
06437-2111
US

V. Phone/Fax

Practice location:
  • Phone: 203-421-3600
  • Fax:
Mailing address:
  • Phone: 203-980-4099
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number12036
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: