Healthcare Provider Details

I. General information

NPI: 1366912701
Provider Name (Legal Business Name): ROZLYN GRACE PORAY APRN, CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ROZLYN GRACE PETERSEN

II. Dates (important events)

Enumeration Date: 11/28/2018
Last Update Date: 12/17/2024
Certification Date: 12/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 CHAPEL ST
NEW HAVEN CT
06511-4440
US

IV. Provider business mailing address

4753 MALLARD LAKE CV
COLLIERVILLE TN
38017-9360
US

V. Phone/Fax

Practice location:
  • Phone: 203-416-9032
  • Fax:
Mailing address:
  • Phone: 207-416-9032
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number138969
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number31389
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number7982
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: