1063412542 NPI number — MS. EILEEN JOY ODONNELL RN, APRN

Table of content: MS. EILEEN JOY ODONNELL RN, APRN (NPI 1063412542)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063412542 NPI number — MS. EILEEN JOY ODONNELL RN, APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ODONNELL
Provider First Name:
EILEEN
Provider Middle Name:
JOY
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
RN, APRN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063412542
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
146 IRONWORKS RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLINTON
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06413-1223
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-664-0466
Provider Business Mailing Address Fax Number:
860-669-3351

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
345 MONTAUK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW LONDON
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06320-4738
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-444-6711
Provider Business Practice Location Address Fax Number:
860-437-0650
Provider Enumeration Date:
07/27/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LW0102X , with the licence number:  000368 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 400000368CT04 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 2V5541 . This is a "HEALTH NET" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 368000 . This is a "CONNECTICARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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