Provider Demographics
NPI:1578512323
Name:DEJESUS, MAHALIA T (FNP-BC)
Entity Type:Individual
Prefix:
First Name:MAHALIA
Middle Name:T
Last Name:DEJESUS
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 CAMBRIDGE DR STE 201
Mailing Address - Street 2:
Mailing Address - City:TRUMBULL
Mailing Address - State:CT
Mailing Address - Zip Code:06611-4763
Mailing Address - Country:US
Mailing Address - Phone:203-335-0195
Mailing Address - Fax:203-335-7293
Practice Address - Street 1:7 CAMBRIDGE DR STE 201
Practice Address - Street 2:
Practice Address - City:TRUMBULL
Practice Address - State:CT
Practice Address - Zip Code:06611-4763
Practice Address - Country:US
Practice Address - Phone:203-335-0195
Practice Address - Fax:203-335-7293
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-09
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003347363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1578512323Medicaid
CT004261799Medicaid
CTQ70036Medicare UPIN