Healthcare Provider Details

I. General information

NPI: 1275091100
Provider Name (Legal Business Name): ANDRE GABRIEL PHILIPP APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/11/2019
Last Update Date: 08/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

437 ORANGE STREET
NEW HAVEN CT
06511
US

IV. Provider business mailing address

437 ORANGE STREET
NEW HAVEN CT
06511
US

V. Phone/Fax

Practice location:
  • Phone: 203-909-6370
  • Fax: 203-909-6374
Mailing address:
  • Phone: 203-909-6370
  • Fax: 203-909-6374

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number8330
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: