Healthcare Provider Details

I. General information

NPI: 1629839584
Provider Name (Legal Business Name): ALBA YESSENIA REVERON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2024
Last Update Date: 01/18/2024
Certification Date: 01/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

157 CHURCH ST STE 1900
NEW HAVEN CT
06510-2100
US

IV. Provider business mailing address

747 CONGRESS AVE
WATERBURY CT
06708-4014
US

V. Phone/Fax

Practice location:
  • Phone: 888-498-1669
  • Fax:
Mailing address:
  • Phone: 203-465-9775
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: