Provider Demographics
NPI:1558364174
Name:ZANDONELLA, MARIA L (APRN)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:L
Last Name:ZANDONELLA
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 PEPPERBUSH DR
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:CT
Mailing Address - Zip Code:06413-1168
Mailing Address - Country:US
Mailing Address - Phone:860-669-5302
Mailing Address - Fax:
Practice Address - Street 1:17 PEPPERBUSH DR
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:CT
Practice Address - Zip Code:06413-1168
Practice Address - Country:US
Practice Address - Phone:860-669-5302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2008-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002961363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004241824Medicaid
CT400002961CT04OtherBLUE SHIELD
CT2V6904OtherHEALTHNET
CT004241824Medicaid
CTD400000362Medicare PIN
CT400002961CT04OtherBLUE SHIELD