Provider Demographics
NPI:1952383036
Name:IAVA, PAMELA A (APRN)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:A
Last Name:IAVA
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:PO BOX 415126
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5126
Mailing Address - Country:US
Mailing Address - Phone:203-384-3975
Mailing Address - Fax:203-384-3829
Practice Address - Street 1:267 GRANT ST
Practice Address - Street 2:BRIDGEPORT HOSPITAL
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06610-2805
Practice Address - Country:US
Practice Address - Phone:203-384-3840
Practice Address - Fax:203-330-7497
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2010-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTE40884163W00000X
CT001353363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT500000667Medicare ID - Type Unspecified