Provider Demographics
NPI:1407033442
Name:DURIVAGE, SHARON E (APRN-BC)
Entity Type:Individual
Prefix:
First Name:SHARON
Middle Name:E
Last Name:DURIVAGE
Suffix:
Gender:F
Credentials:APRN-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:GUILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06437-2468
Mailing Address - Country:US
Mailing Address - Phone:203-689-5307
Mailing Address - Fax:203-689-5803
Practice Address - Street 1:303 CHURCH ST
Practice Address - Street 2:
Practice Address - City:GUILFORD
Practice Address - State:CT
Practice Address - Zip Code:06437-2468
Practice Address - Country:US
Practice Address - Phone:203-689-5307
Practice Address - Fax:203-689-5803
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-22
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00150200364SP0808X
CT004454364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
No364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD400075042Medicare PIN