Healthcare Provider Details

I. General information

NPI: 1518278910
Provider Name (Legal Business Name): MARYANN MCDONOUGH APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2010
Last Update Date: 06/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 YORK ST, CB-2041
NEW HAVEN CT
06510-3220
US

IV. Provider business mailing address

20 YORK ST, CB-2041
NEW HAVEN CT
06510-3220
US

V. Phone/Fax

Practice location:
  • Phone: 203-688-4748
  • Fax: 203-688-4740
Mailing address:
  • Phone: 203-688-4242
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5794
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number5794
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number351656
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number351656
License Number StateNY
# 5
Primary TaxonomyN
Taxonomy Code163WI0500X
TaxonomyInfusion Therapy Registered Nurse
License Number351656
License Number StateNY
# 6
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number351656
License Number StateNY
# 7
Primary TaxonomyN
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License Number351656
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: