Basic Information
| Provider Information | |||||||||
| NPI: | 1467585414 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCGILLICUDDY | ||||||||
| FirstName: | TINA | ||||||||
| MiddleName: | KATSARIKAS | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | APRN NURSE PRACTITIO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 COLUMBUS AVE | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065191233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035033250 | ||||||||
| FaxNumber: | 2035033254 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 COLUMBUS AVE | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065191233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035033250 | ||||||||
| FaxNumber: | 2035033254 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2007 | ||||||||
| LastUpdateDate: | 12/12/2011 | ||||||||
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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 | 133V00000X | 151957 | TN | N | Dietary & Nutritional Service Providers | Dietitian, Registered | 163W00000X | 079084 | CT | N | Nursing Service Providers | Registered Nurse | 363LP0200X | 003531 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 004235900 | 05 | CT | MEDICAID |