Basic Information
| Provider Information | |||||||||
| NPI: | 1700412111 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FEGLEY | ||||||||
| FirstName: | JEREZEM | ||||||||
| MiddleName: | SISON | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 555 WILLARD AVE | ||||||||
| Address2: | |||||||||
| City: | NEWINGTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061112631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606666951 | ||||||||
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| Practice Location | |||||||||
| Address1: | 950 CAMPBELL AVE | ||||||||
| Address2: | |||||||||
| City: | WEST HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065162770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2039325711 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2020 | ||||||||
| LastUpdateDate: | 10/04/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 345768 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 10250 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.