Healthcare Provider Details

I. General information

NPI: 1497750798
Provider Name (Legal Business Name): SHORELINE MEDICAL ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2005
Last Update Date: 09/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1353 BOSTON POST RD
MADISON CT
06443-3445
US

IV. Provider business mailing address

1353 BOSTON POST RD
MADISON CT
06443-3445
US

V. Phone/Fax

Practice location:
  • Phone: 203-245-4933
  • Fax: 203-245-4399
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number006159
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: DR. JENNIFER P SWENSON
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 203-245-4933