Basic Information
| Provider Information | |||||||||
| NPI: | 1346536372 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STANKO | ||||||||
| FirstName: | RAQUEL | ||||||||
| MiddleName: | |||||||||
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| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 913 STATE ST | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065113926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035033351 | ||||||||
| FaxNumber: | 2037810276 | ||||||||
| Practice Location | |||||||||
| Address1: | 232 CEDAR ST | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065191610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035033300 | ||||||||
| FaxNumber: | 2037810276 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2011 | ||||||||
| LastUpdateDate: | 06/28/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WA0400X | 79119 | CT | Y | Nursing Service Providers | Registered Nurse | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 004235918 | 05 | CT | MEDICAID | 004235900 | 05 | CT | MEDICAID |