Provider Demographics
NPI:1891705307
Name:SCHUSTEK, MARY ELIZABETH (APRN)
Entity Type:Individual
Prefix:MISS
First Name:MARY
Middle Name:ELIZABETH
Last Name:SCHUSTEK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:MRS
Other - First Name:MARY
Other - Middle Name:ELIZABETH
Other - Last Name:DOOLITTLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:67 MASONIC AVE
Mailing Address - Street 2:SUITE 3100
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-3095
Mailing Address - Country:US
Mailing Address - Phone:203-284-3144
Mailing Address - Fax:203-284-3140
Practice Address - Street 1:67 MASONIC AVE
Practice Address - Street 2:SUITE 3100
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492-3095
Practice Address - Country:US
Practice Address - Phone:203-284-3144
Practice Address - Fax:203-284-3140
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2016-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2742207R00000X
SCAPN2742363LF0000X
CT006357363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP0948Medicaid
Q42721179OtherCHAMPUS
Q52978Medicare UPIN
SCAA10945200Medicare ID - Type Unspecified
Q42721179OtherCHAMPUS