Provider Demographics
NPI:1598420309
Name:STEVENSON, MARQUITA
Entity Type:Individual
Prefix:
First Name:MARQUITA
Middle Name:
Last Name:STEVENSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 SMITH ST
Mailing Address - Street 2:
Mailing Address - City:WEST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06516-4516
Mailing Address - Country:US
Mailing Address - Phone:203-521-5406
Mailing Address - Fax:
Practice Address - Street 1:2045 DIXWELL AVE
Practice Address - Street 2:
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06514-2405
Practice Address - Country:US
Practice Address - Phone:203-287-0835
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-05
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT10211363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily