Provider Demographics
NPI:1134140098
Name:YOUNG-DECIANTIS, ANDREA (CNM)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:YOUNG-DECIANTIS
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06106-1806
Mailing Address - Country:US
Mailing Address - Phone:860-522-9913
Mailing Address - Fax:
Practice Address - Street 1:1 MAIN ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-1806
Practice Address - Country:US
Practice Address - Phone:860-525-1900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-23
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMW00079176B00000X
CT000195367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No176B00000XOther Service ProvidersMidwife