Provider Demographics
NPI:1396412722
Name:SERRA, SHANNON
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:SERRA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 CEDAR STREET, TMP 3
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06510
Mailing Address - Country:US
Mailing Address - Phone:203-785-2802
Mailing Address - Fax:203-785-6664
Practice Address - Street 1:333 CEDAR STREET, TMP 3
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510
Practice Address - Country:US
Practice Address - Phone:203-785-2802
Practice Address - Fax:203-785-6664
Is Sole Proprietor?:No
Enumeration Date:2021-08-24
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT009935363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner