Healthcare Provider Details

I. General information

NPI: 1346256062
Provider Name (Legal Business Name): MICHELLE M CAMPBELL CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MICHELLE M BREAULT

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 09/17/2024
Certification Date: 09/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 TRAP FALLS ROAD SUITE 414
SHELTON CT
06484
US

IV. Provider business mailing address

99 EAST RIVER DRIVE 5TH FLOOR
EAST HARTFORD CT
06108-7301
US

V. Phone/Fax

Practice location:
  • Phone: 203-929-7353
  • Fax: 203-929-0756
Mailing address:
  • Phone: 860-282-0833
  • Fax: 860-282-0170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberL60A00471
License Number StateDE
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN11014918
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: