Provider Demographics
NPI:1912372350
Name:MESEROLE, SHAYLICE MICHELLE (APRN)
Entity Type:Individual
Prefix:
First Name:SHAYLICE
Middle Name:MICHELLE
Last Name:MESEROLE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 CLARK AVE
Mailing Address - Street 2:
Mailing Address - City:BRANFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06405-4730
Mailing Address - Country:US
Mailing Address - Phone:312-696-9321
Mailing Address - Fax:
Practice Address - Street 1:415 MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516-4296
Practice Address - Country:US
Practice Address - Phone:203-931-1184
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-10
Last Update Date:2020-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT116134163W00000X
CT6406363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse