Provider Demographics
NPI:1114063914
Name:NICOLETTI, DOREEN (CRNA)
Entity Type:Individual
Prefix:
First Name:DOREEN
Middle Name:
Last Name:NICOLETTI
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 1:2 TRAP FALLS RD
Mailing Address - Street 2:SUITE 414
Mailing Address - City:SHELTON
Mailing Address - State:CT
Mailing Address - Zip Code:06484-4616
Mailing Address - Country:US
Mailing Address - Phone:203-929-7353
Mailing Address - Fax:203-929-0756
Practice Address - Street 1:99 E RIVER DR
Practice Address - Street 2:5TH FLOOR
Practice Address - City:EAST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06108-3288
Practice Address - Country:US
Practice Address - Phone:860-282-4128
Practice Address - Fax:860-289-0746
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2015-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000013367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT430000057Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER