Healthcare Provider Details

I. General information

NPI: 1336542984
Provider Name (Legal Business Name): MISS DORINE JEUDI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2014
Last Update Date: 09/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

152 MYNO LANE
STAMFORD CT
06902
US

IV. Provider business mailing address

152 MYANO LN
STAMFORD CT
06902-2122
US

V. Phone/Fax

Practice location:
  • Phone: 203-550-3753
  • Fax:
Mailing address:
  • Phone: 203-550-3753
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number093204
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: