Provider Demographics
NPI:1104828136
Name:CUNNINGHAM, PAMELA J (CRNA)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:J
Last Name:CUNNINGHAM
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 STEVENS ST
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06850-3852
Mailing Address - Country:US
Mailing Address - Phone:203-852-3141
Mailing Address - Fax:203-852-2527
Practice Address - Street 1:24 STEVENS ST
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06850
Practice Address - Country:US
Practice Address - Phone:203-852-3141
Practice Address - Fax:203-852-2527
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000259171100000X
NY452674367500000X
CT15367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYR3C771Medicare ID - Type Unspecified