Provider Demographics
NPI:1730501727
Name:TAVERAS, SHADY (PMHNP)
Entity type:Individual
Prefix:
First Name:SHADY
Middle Name:
Last Name:TAVERAS
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:SHADY
Other - Middle Name:
Other - Last Name:FEQUIERE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PMHNP
Mailing Address - Street 1:346 DAYTON RD
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-3112
Mailing Address - Country:US
Mailing Address - Phone:203-450-6515
Mailing Address - Fax:
Practice Address - Street 1:346 DAYTON RD
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-3112
Practice Address - Country:US
Practice Address - Phone:203-450-6515
Practice Address - Fax:959-666-8678
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-10
Last Update Date:2025-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT14273363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008042339Medicaid
CT008023170Medicaid
CT008024427Medicaid