Provider Demographics
NPI:1164590915
Name:MYCHASKIW, DONNA (PD,MS)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:
Last Name:MYCHASKIW
Suffix:
Gender:F
Credentials:PD,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 ABBOTT FARM RD
Mailing Address - Street 2:P.O. BOX 1213
Mailing Address - City:MIDDLEBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06762-1213
Mailing Address - Country:US
Mailing Address - Phone:203-758-9280
Mailing Address - Fax:203-758-9280
Practice Address - Street 1:11 ABBOTT FARM RD
Practice Address - Street 2:
Practice Address - City:MIDDLEBURY
Practice Address - State:CT
Practice Address - Zip Code:06762-1213
Practice Address - Country:US
Practice Address - Phone:203-758-9280
Practice Address - Fax:203-758-9280
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT63941835N1003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835N1003XPharmacy Service ProvidersPharmacistNutrition Support