Healthcare Provider Details

I. General information

NPI: 1144710484
Provider Name (Legal Business Name): DANIELLA NUSSBAUM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2018
Last Update Date: 09/01/2023
Certification Date: 09/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 YORK ST
NEW HAVEN CT
06510-3220
US

IV. Provider business mailing address

PO BOX 208051
NEW HAVEN CT
06520-8051
US

V. Phone/Fax

Practice location:
  • Phone: 203-688-4242
  • Fax:
Mailing address:
  • Phone: 203-785-4304
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP3000X
TaxonomyPediatric Anesthesiology Physician
License Number74206
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: