Basic Information
| Provider Information | |||||||||
| NPI: | 1487052189 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CRISCUOLO | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | ALISON | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 JORDAN LN | ||||||||
| Address2: | |||||||||
| City: | WETHERSFIELD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061091278 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602630253 | ||||||||
| FaxNumber: | 8602630262 | ||||||||
| Practice Location | |||||||||
| Address1: | 27 SYCAMORE ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | GLASTONBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060337208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606590581 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2014 | ||||||||
| LastUpdateDate: | 06/28/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 005924 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.