1720194939 NPI number — MRS. ANNA HAZEL GODDARD APRN, CPNP-PC

Table of content: MRS. ANNA HAZEL GODDARD APRN, CPNP-PC (NPI 1720194939)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720194939 NPI number — MRS. ANNA HAZEL GODDARD APRN, CPNP-PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GODDARD
Provider First Name:
ANNA
Provider Middle Name:
HAZEL
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
APRN, CPNP-PC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
TIELSCH-GODDARD
Provider Other First Name:
ANNA
Provider Other Middle Name:
HAZEL
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
APRN, CPNP-PC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1720194939
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/05/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
255 HEMPSTEAD ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW LONDON
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06320-6204
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-443-2896
Provider Business Mailing Address Fax Number:
860-442-5909

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7 VAUXHALL ST
Provider Second Line Business Practice Location Address:
CHILD & FAMILY AGENCY OF SECT, INC.
Provider Business Practice Location Address City Name:
NEW LONDON
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06320-5711
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-442-2797
Provider Business Practice Location Address Fax Number:
860-701-3776
Provider Enumeration Date:
08/21/2006

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: 363LP0200X , with the licence number:  765853 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0200X , with the licence number: 3291 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 163W00000X , with the licence number: 73362 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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