Healthcare Provider Details

I. General information

NPI: 1003668294
Provider Name (Legal Business Name): YULIYA KOSHKINA AGACNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2024
Last Update Date: 10/08/2024
Certification Date: 10/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

761 MAIN AVE STE 201
NORWALK CT
06851-1080
US

IV. Provider business mailing address

761 MAIN AVE STE 201
NORWALK CT
06851-1080
US

V. Phone/Fax

Practice location:
  • Phone: 203-853-5000
  • Fax: 203-853-5001
Mailing address:
  • Phone: 929-294-1511
  • Fax: 203-853-5001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number12772
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: