1396792156 NPI number — MALCOLM HAUTHAWAY PAC

Table of content: LINDA SUE TETTAMBEL R.N. (NPI 1902976756)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396792156 NPI number — MALCOLM HAUTHAWAY PAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HAUTHAWAY
Provider First Name:
MALCOLM
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PAC
Provider Gender Code:
M

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:
1396792156
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/18/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7 HOLLAND WAY FL 1
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EXETER
Provider Business Mailing Address State Name:
NH
Provider Business Mailing Address Postal Code:
03833-2997
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
603-778-7975
Provider Business Mailing Address Fax Number:
603-778-7964

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
330 BORTHWICK AVE STE 308
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTSMOUTH
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03801-7112
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-431-5242
Provider Business Practice Location Address Fax Number:
603-433-4045
Provider Enumeration Date:
05/27/2006

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: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3076274 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".




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