Provider Demographics
NPI:1093819146
Name:MAGENHEIMER, ELIZABETH (FNP APRN)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:MAGENHEIMER
Suffix:
Gender:F
Credentials:FNP APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 HUNTINGTON STREET
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511
Mailing Address - Country:US
Mailing Address - Phone:203-787-1383
Mailing Address - Fax:
Practice Address - Street 1:374 GRAND AVENUE
Practice Address - Street 2:FAIR HAVEN COMMUNITY HEALTH CTR
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06513
Practice Address - Country:US
Practice Address - Phone:203-777-7411
Practice Address - Fax:203-777-8506
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000756363LC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LC1500XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
183832OtherWELLCARE
756000OtherCT CARE