Provider Demographics
NPI:1619244043
Name:CIMMINELLO, AMY (PA-C)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:CIMMINELLO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:
Other - Last Name:BERNHEIM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:6 RESEARCH DR STE 105
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:CT
Mailing Address - Zip Code:06484-6228
Mailing Address - Country:US
Mailing Address - Phone:203-210-6340
Mailing Address - Fax:203-502-2615
Practice Address - Street 1:495 HAWLEY LN STE 2A
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:CT
Practice Address - Zip Code:06614-1597
Practice Address - Country:US
Practice Address - Phone:203-375-2861
Practice Address - Fax:203-502-2615
Is Sole Proprietor?:No
Enumeration Date:2011-11-30
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001330363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004053310Medicaid