Provider Demographics
NPI:1487338307
Name:RENZULLO, SHAYLAH MARIE (PA)
Entity type:Individual
Prefix:
First Name:SHAYLAH
Middle Name:MARIE
Last Name:RENZULLO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71 HAYNES ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06040-4131
Mailing Address - Country:US
Mailing Address - Phone:860-647-4777
Mailing Address - Fax:860-647-6862
Practice Address - Street 1:435 LEWIS AVE
Practice Address - Street 2:
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06451-2101
Practice Address - Country:US
Practice Address - Phone:203-694-8200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-12
Last Update Date:2025-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT7247363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant