1235965898 NPI number — MRS. AMANDA JOYCE LONGOLUCCO RD

Table of content: XAVIER JAY BURGESS (NPI 1093671265)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235965898 NPI number — MRS. AMANDA JOYCE LONGOLUCCO RD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LONGOLUCCO
Provider First Name:
AMANDA
Provider Middle Name:
JOYCE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MCGINN
Provider Other First Name:
AMANDA
Provider Other Middle Name:
JOYCE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
RD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1235965898
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/10/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9 RICKY LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PRESTON
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06365-8620
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-215-5574
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
66 FRANKLIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORWICH
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06360-5806
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-934-4926
Provider Business Practice Location Address Fax Number:
866-823-8168
Provider Enumeration Date:
09/10/2024

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: 133V00000X , with the licence number:  LDN00935 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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