1366927261 NPI number — LISA MAZZOLA

Table of content: LISA MAZZOLA (NPI 1366927261)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366927261 NPI number — LISA MAZZOLA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MAZZOLA
Provider First Name:
LISA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KIMLINGEN
Provider Other First Name:
LISA
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:
1366927261
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/27/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
995 DAY HILL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINDSOR
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06095-1722
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-731-5522
Provider Business Mailing Address Fax Number:
860-731-5536

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
71 WESTCOTT RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DANIELSON
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06239-2929
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-774-7179
Provider Business Practice Location Address Fax Number:
860-779-6526
Provider Enumeration Date:
09/27/2018

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: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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