Provider Demographics
NPI:1972547495
Name:MASTRIANI, DEBORAH A (APRN)
Entity type:Individual
Prefix:MRS
First Name:DEBORAH
Middle Name:A
Last Name:MASTRIANI
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 1:21 W MAIN ST
Mailing Address - Street 2:ONE EXCHANGE PLACE BLDG-3RD FLOOR
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06702-2013
Mailing Address - Country:US
Mailing Address - Phone:203-574-3777
Mailing Address - Fax:203-755-1708
Practice Address - Street 1:21 W MAIN ST
Practice Address - Street 2:ONE EXCHANGE PLACE BLDG-3RD FLOOR
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06702-2013
Practice Address - Country:US
Practice Address - Phone:203-574-3777
Practice Address - Fax:203-755-1708
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002113363L00000X, 207YS0012X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207YS0012XAllopathic & Osteopathic PhysiciansOtolaryngologySleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004238839Medicaid
CT500000764Medicare ID - Type UnspecifiedMEDICARE INDIVIDUAL I.D #
CT004238839Medicaid