Healthcare Provider Details

I. General information

NPI: 1871069559
Provider Name (Legal Business Name): STEPHANIE FIORENTINO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2018
Last Update Date: 11/03/2020
Certification Date: 11/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 PARK ST
NEW HAVEN CT
06504-8901
US

IV. Provider business mailing address

36 CARINA RD
NORTH HAVEN CT
06473-2403
US

V. Phone/Fax

Practice location:
  • Phone: 203-688-4242
  • Fax:
Mailing address:
  • Phone: 203-317-1855
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4190
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: