Provider Demographics
NPI:1467585414
Name:MCGILLICUDDY, TINA KATSARIKAS (APRN NURSE PRACTITIO)
Entity Type:Individual
Prefix:MRS
First Name:TINA
Middle Name:KATSARIKAS
Last Name:MCGILLICUDDY
Suffix:
Gender:F
Credentials:APRN NURSE PRACTITIO
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Mailing Address - Street 1:400 COLUMBUS AVE
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06519-1233
Mailing Address - Country:US
Mailing Address - Phone:203-503-3250
Mailing Address - Fax:203-503-3254
Practice Address - Street 1:400 COLUMBUS AVE
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06519-1233
Practice Address - Country:US
Practice Address - Phone:203-503-3250
Practice Address - Fax:203-503-3254
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2011-12-12
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TN151957133V00000X
CT079084163W00000X
CT003531363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004235900Medicaid