Basic Information
| Provider Information | |||||||||
| NPI: | 1972600799 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HALLY | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | SPADA | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 122 RED HILL RD | ||||||||
| Address2: | |||||||||
| City: | BRANFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064053361 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2034810294 | ||||||||
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| Practice Location | |||||||||
| Address1: | 200 ORCHARD ST | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065115363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037893029 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 03/21/2016 | ||||||||
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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 | 367A00000X | 000026 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 004144367CL | 05 | CT | MEDICAID |