Provider Demographics
NPI:1639286362
Name:IPPOLITO, CARMEN IRIS (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:CARMEN
Middle Name:IRIS
Last Name:IPPOLITO
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 WOODMERE CIRCLE
Mailing Address - Street 2:
Mailing Address - City:NORTH HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06473
Mailing Address - Country:US
Mailing Address - Phone:203-248-6009
Mailing Address - Fax:
Practice Address - Street 1:1423 CHAPEL
Practice Address - Street 2:ST RAPHAEL HOSPITAL ANESTHESIA ASSOCIATES
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511
Practice Address - Country:US
Practice Address - Phone:203-789-3538
Practice Address - Fax:203-865-2983
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2013-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTAPRN000133367500000X
CTRNE35834367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
430000238Medicare ID - Type Unspecified