Healthcare Provider Details

I. General information

NPI: 1396412722
Provider Name (Legal Business Name): SHANNON SERRA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2021
Last Update Date: 09/03/2021
Certification Date: 09/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 CEDAR STREET, TMP 3
NEW HAVEN CT
06510
US

IV. Provider business mailing address

333 CEDAR STREET, TMP 3
NEW HAVEN CT
06510
US

V. Phone/Fax

Practice location:
  • Phone: 203-785-2802
  • Fax: 203-785-6664
Mailing address:
  • Phone: 203-785-2802
  • Fax: 203-785-6664

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number009935
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: