Healthcare Provider Details

I. General information

NPI: 1255482147
Provider Name (Legal Business Name): MARIYA YAKUBOV NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 11/06/2025
Certification Date: 11/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

764 CAMPBELL AVE STE F
WEST HAVEN CT
06516-3786
US

IV. Provider business mailing address

24 HOSPITAL AVE
DANBURY CT
06810-6099
US

V. Phone/Fax

Practice location:
  • Phone: 203-443-9500
  • Fax: 203-902-0509
Mailing address:
  • Phone: 203-739-6586
  • Fax: 203-739-1614

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number8776
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number303909
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number8776
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: