Provider Demographics
NPI:1598376162
Name:KUSHEBA, JODY (APRN)
Entity Type:Individual
Prefix:MRS
First Name:JODY
Middle Name:
Last Name:KUSHEBA
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 1:764 CAMPBELL AVE STE F
Mailing Address - Street 2:
Mailing Address - City:WEST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06516-3786
Mailing Address - Country:US
Mailing Address - Phone:203-395-4867
Mailing Address - Fax:203-902-0509
Practice Address - Street 1:764 CAMPBELL AVE STE F
Practice Address - Street 2:
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516-3786
Practice Address - Country:US
Practice Address - Phone:203-443-9500
Practice Address - Fax:203-902-0509
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-16
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT12.009109363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily