Provider Demographics
NPI:1982072591
Name:KUKULKA, SHANNON P (APRN)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:P
Last Name:KUKULKA
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 1:874 HOWARD AVE
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06519-1106
Mailing Address - Country:US
Mailing Address - Phone:203-688-8200
Mailing Address - Fax:203-688-8200
Practice Address - Street 1:874 HOWARD AVE
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06519-1106
Practice Address - Country:US
Practice Address - Phone:203-688-8200
Practice Address - Fax:203-688-8200
Is Sole Proprietor?:No
Enumeration Date:2015-09-14
Last Update Date:2018-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT6878363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1982072591OtherUNITED HEALTHCARE
CT1982072591OtherMULTIPLAN
CT4869372OtherAETNA
CT1982072591OtherANTHEM
CT1982072591Medicaid
CTAA533003OtherHARVARD PILGRIM
CTP5602305OtherOXFORD
CT6028631OtherCIGNA
CTP5602305OtherOXFORD