1417936790 NPI number — SUSAN VONTELL APRN

Table of content: SUSAN VONTELL APRN (NPI 1417936790)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417936790 NPI number — SUSAN VONTELL APRN

Organization/Personal Information

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

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JONES
Provider Other First Name:
SUSAN
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:
1417936790
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
538 LITCHFIELD ST
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
TORRINGTON
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06790-6669
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-489-7017
Provider Business Mailing Address Fax Number:
860-489-8943

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
538 LITCHFIELD ST
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
TORRINGTON
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06790-6669
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-489-7017
Provider Business Practice Location Address Fax Number:
860-489-8943
Provider Enumeration Date:
01/13/2006

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: 363L00000X , with the licence number:  001827 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 018270 . This is a "CONNECTICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0220785 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 004243333-00 . This is a "BLUECARE FAMILY PLAN (MCD" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: Q09265 . This identifiers is of the category "MEDICARE UPIN".
  • Identifier: 400001827CT01 . This is a "ANTHEM BC/BS" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".