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General NPI Number Information
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NPI Number | 1962680934
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Entity Type | Organization
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Legal Business Name | NEW HAVEN PEDIATRIC & ADOLESCENT MEDICAL SERV
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Dates
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Enumeration Date | 02/01/2008
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Last Update Date | 02/01/2008
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Provider Practice Location Address
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Address Line | 1423 CHAPEL ST UNIT 2B
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City | NEW HAVEN
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State | CT
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Zip | 06511
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Country | US
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Telephone | 203-752-0706
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Fax | 203-772-0387
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Provider Business Mailing Address
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Address Line | 1423 CHAPEL ST UNIT 2B
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City | NEW HAVEN
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State | CT
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Zip | 06511
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Country | US
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Telephone | 203-752-0706
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Fax | 203-772-0387
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | ANGEL JACKSON
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Credential |
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Telephone | 203-906-3854
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0200X
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Taxonomy Name | Pediatric Nurse Practitioner
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License Number | 0002815
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License Number State | CT
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Taxonomy #2
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 0136872
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License Number State | CT
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