Healthcare Provider Details

I. General information

NPI: 1821456989
Provider Name (Legal Business Name): SAFIRA H. IDDRISS CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/04/2016
Last Update Date: 09/19/2023
Certification Date: 09/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

365 MONTAUK AVE
NEW LONDON CT
06320-4700
US

IV. Provider business mailing address

136 RENEE S WAY
GUILFORD CT
06437-1266
US

V. Phone/Fax

Practice location:
  • Phone: --
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number7429
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number102169
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1056973
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN2290428
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: