Provider Demographics
NPI:1871044271
Name:ZACHARIAS, JEENU MARY (CRNA)
Entity Type:Individual
Prefix:
First Name:JEENU
Middle Name:MARY
Last Name:ZACHARIAS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:JEENU
Other - Middle Name:MARY
Other - Last Name:GEORGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:25 BROADMEADOW RD
Mailing Address - Street 2:
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-6045
Mailing Address - Country:US
Mailing Address - Phone:203-300-0045
Mailing Address - Fax:
Practice Address - Street 1:333 CEDAR ST, TMP3
Practice Address - Street 2:YALE UNIVERSITY, DEPARTMENT OF ANESTHESIOLOGY
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06520-8051
Practice Address - Country:US
Practice Address - Phone:203-737-1549
Practice Address - Fax:203-785-6664
Is Sole Proprietor?:No
Enumeration Date:2016-10-20
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT078356163W00000X
CT6841367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT6841OtherAPRN LICENSE
CT078356OtherRN LICENSE
CT367500000XMedicare PIN