Healthcare Provider Details

I. General information

NPI: 1053626929
Provider Name (Legal Business Name): MADONNA KAY FASULA A.P.R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2010
Last Update Date: 08/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 YORK ST STE 2J
NEW HAVEN CT
06511-5664
US

IV. Provider business mailing address

100 YORK ST STE 2J
NEW HAVEN CT
06511-5664
US

V. Phone/Fax

Practice location:
  • Phone: 203-764-9131
  • Fax: 203-764-5963
Mailing address:
  • Phone: 203-764-9131
  • Fax: 203-764-5963

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License Number002435
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: