Healthcare Provider Details

I. General information

NPI: 1013179902
Provider Name (Legal Business Name): ILLUME FERTILITY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2008
Last Update Date: 04/04/2022
Certification Date: 04/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

761 MAIN AVE SUITE 200
NORWALK CT
06851-1080
US

IV. Provider business mailing address

761 MAIN AVE SUITE 200
NORWALK CT
06851-1080
US

V. Phone/Fax

Practice location:
  • Phone: 203-750-7400
  • Fax:
Mailing address:
  • Phone: 203-750-7400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0006X
TaxonomyAmbulatory Fertility Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number0320
License Number StateCT

VIII. Authorized Official

Name: ROBIN MANGIERI
Title or Position: CEO
Credential:
Phone: 203-750-7400