Provider Demographics
NPI:1073677258
Name:WEATHERBY, STEPHEN DOUGLAS (CRNA)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:DOUGLAS
Last Name:WEATHERBY
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 BIRCH MILL TRL
Mailing Address - Street 2:
Mailing Address - City:ESSEX
Mailing Address - State:CT
Mailing Address - Zip Code:06426-1204
Mailing Address - Country:US
Mailing Address - Phone:960-767-7974
Mailing Address - Fax:
Practice Address - Street 1:391 BROAD ST
Practice Address - Street 2:
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06450-5844
Practice Address - Country:US
Practice Address - Phone:203-634-0523
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000769367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered