Provider Demographics
NPI:1932101854
Name:PECCERILLO, SANDRA (APRN)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:PECCERILLO
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 1:231 COURT ST
Mailing Address - Street 2:
Mailing Address - City:WEST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06516-4932
Mailing Address - Country:US
Mailing Address - Phone:120-640-8551
Mailing Address - Fax:
Practice Address - Street 1:1062 BARNES RD
Practice Address - Street 2:
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492-6012
Practice Address - Country:US
Practice Address - Phone:203-294-6328
Practice Address - Fax:203-294-6346
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1730363LF0000X
CT001730363LP0200X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT00421284101Medicaid
500000758Medicare ID - Type Unspecified
CT00421284101Medicaid