Healthcare Provider Details

I. General information

NPI: 1427604594
Provider Name (Legal Business Name): SAMANTHA ANN PACILEO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2019
Last Update Date: 11/01/2023
Certification Date: 11/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

64 ROBBINS ST
WATERBURY CT
06708-2600
US

IV. Provider business mailing address

420 LAKE SHORE DR
MIDDLEBURY CT
06762-3473
US

V. Phone/Fax

Practice location:
  • Phone: 203-573-6000
  • Fax:
Mailing address:
  • Phone: 203-217-5522
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4892
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: