Healthcare Provider Details

I. General information

NPI: 1225449028
Provider Name (Legal Business Name): MICHELLE EILEEN ZACK CRNA, APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2014
Last Update Date: 02/06/2023
Certification Date: 02/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 STEVENS ST
NORWALK CT
06850-3852
US

IV. Provider business mailing address

27 HIGH RIDGE RD
SHELTON CT
06484-5008
US

V. Phone/Fax

Practice location:
  • Phone: 203-852-2276
  • Fax:
Mailing address:
  • Phone: 203-521-1966
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number72128
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number93350
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: