Provider Demographics
NPI:1972600799
Name:HALLY, SUSAN SPADA (CNM)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:SPADA
Last Name:HALLY
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 RED HILL RD
Mailing Address - Street 2:
Mailing Address - City:BRANFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06405-3361
Mailing Address - Country:US
Mailing Address - Phone:203-481-0294
Mailing Address - Fax:
Practice Address - Street 1:200 ORCHARD ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-5363
Practice Address - Country:US
Practice Address - Phone:203-789-3029
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2016-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000026367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004144367CLMedicaid