Provider Demographics
NPI:1154564284
Name:BOOTH, DAVID J (APRN)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:J
Last Name:BOOTH
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:I CELLINI PLACE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:WEST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06516-1666
Mailing Address - Country:US
Mailing Address - Phone:203-932-6481
Mailing Address - Fax:203-932-4051
Practice Address - Street 1:I CELLINI PLACE
Practice Address - Street 2:SUITE 102
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516-1666
Practice Address - Country:US
Practice Address - Phone:203-932-6481
Practice Address - Fax:203-932-4051
Is Sole Proprietor?:No
Enumeration Date:2009-04-20
Last Update Date:2023-03-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CT071318163W00000X
CT004113363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD400003865Medicare UPIN