Healthcare Provider Details

I. General information

NPI: 1881902302
Provider Name (Legal Business Name): MRS. ANGELA KATIE MERCURIO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2010
Last Update Date: 11/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1423 CHAPEL ST
NEW HAVEN CT
06511-4411
US

IV. Provider business mailing address

196 WORMWOOD RD
FAIRFIELD CT
06824
US

V. Phone/Fax

Practice location:
  • Phone: 203-688-3540
  • Fax:
Mailing address:
  • Phone: 203-887-4491
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number073584
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: