Basic Information
| Provider Information | |||||||||
| NPI: | 1598010407 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DECEW | ||||||||
| FirstName: | AMANDA | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 374 GRAND AVE | ||||||||
| Address2: | FAIR HAVEN COMMUNITY HEALTH CENTER ATTN: HR | ||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065133733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037777411 | ||||||||
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| Practice Location | |||||||||
| Address1: | 374 GRAND AVE | ||||||||
| Address2: | FAIR HAVEN COMMUNITY HEALTH CENTER | ||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065133733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037777411 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2012 | ||||||||
| LastUpdateDate: | 07/14/2016 | ||||||||
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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 | 163W00000X | 98866 | CT | N | Nursing Service Providers | Registered Nurse | 363LF0000X | 005069 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 008042107 | 05 | CT | MEDICAID |