Provider Demographics
NPI:1053626929
Name:FASULA, MADONNA KAY (APRN)
Entity type:Individual
Prefix:MRS
First Name:MADONNA
Middle Name:KAY
Last Name:FASULA
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 YORK ST STE 2J
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-5664
Mailing Address - Country:US
Mailing Address - Phone:203-764-9131
Mailing Address - Fax:203-764-5963
Practice Address - Street 1:100 YORK ST STE 2J
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-5664
Practice Address - Country:US
Practice Address - Phone:203-764-9131
Practice Address - Fax:203-764-5963
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-16
Last Update Date:2010-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002435364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult