1699966630 NPI number — MRS. ANNA FUSSELL SORENSEN NP

Table of content: MRS. ANNA FUSSELL SORENSEN NP (NPI 1699966630)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699966630 NPI number — MRS. ANNA FUSSELL SORENSEN NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SORENSEN
Provider First Name:
ANNA
Provider Middle Name:
FUSSELL
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FUSSELL
Provider Other First Name:
ANNA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1699966630
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/11/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 679-B
Provider Second Line Business Mailing Address:
601 ELMWOOD AVE.
Provider Business Mailing Address City Name:
ROCHESTER
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14642-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
585-273-3760
Provider Business Mailing Address Fax Number:
585-273-1129

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
995 SENATOR KEATING BLVD
Provider Second Line Business Practice Location Address:
BLDG E, SUITE 340
Provider Business Practice Location Address City Name:
ROCHESTER
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14618-2775
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
585-273-3760
Provider Business Practice Location Address Fax Number:
585-273-1129
Provider Enumeration Date:
08/06/2007

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: 163W00000X , with the licence number:  508373-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 33336777 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 163W00000X , with the licence number: 336777 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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