Provider Demographics
NPI:1093743908
Name:DAGOSTINO, SUSAN (APRN)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:DAGOSTINO
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 HART ST
Mailing Address - Street 2:
Mailing Address - City:NEW BRITAIN
Mailing Address - State:CT
Mailing Address - Zip Code:06052-1743
Mailing Address - Country:US
Mailing Address - Phone:860-229-0100
Mailing Address - Fax:860-225-2647
Practice Address - Street 1:40 HART ST
Practice Address - Street 2:
Practice Address - City:NEW BRITAIN
Practice Address - State:CT
Practice Address - Zip Code:06052-1743
Practice Address - Country:US
Practice Address - Phone:860-229-0100
Practice Address - Fax:860-225-2647
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2009-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTE50759363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT400001941CT01OtherBLUE CROSS
CT194100OtherCONNECTICARE
CT500008445OtherRAILROAD MEDICARE
CT400001941CT01OtherBLUE CROSS
CTS79317Medicare UPIN