Healthcare Provider Details

I. General information

NPI: 1871044271
Provider Name (Legal Business Name): JEENU MARY ZACHARIAS CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JEENU MARY GEORGE RN

II. Dates (important events)

Enumeration Date: 10/20/2016
Last Update Date: 12/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 CEDAR ST, TMP3 YALE UNIVERSITY, DEPARTMENT OF ANESTHESIOLOGY
NEW HAVEN CT
06520-8051
US

IV. Provider business mailing address

25 BROADMEADOW RD
WALLINGFORD CT
06492-6045
US

V. Phone/Fax

Practice location:
  • Phone: 203-737-1549
  • Fax: 203-785-6664
Mailing address:
  • Phone: 203-300-0045
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number078356
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number6841
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: