Provider Demographics
NPI:1194581702
Name:SUYDAM, MOLLY (APRN)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:SUYDAM
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 1:29 HALLMARK HILL DR
Mailing Address - Street 2:
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-3450
Mailing Address - Country:US
Mailing Address - Phone:860-712-7201
Mailing Address - Fax:
Practice Address - Street 1:4A DEVINE ST
Practice Address - Street 2:
Practice Address - City:NORTH HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06473-2142
Practice Address - Country:US
Practice Address - Phone:203-843-9010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-22
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT13530363L00000X
CT157641163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse