1639471717 NPI number — ANGELINA BISSONNETTE

Table of content: ANGELINA BISSONNETTE (NPI 1639471717)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639471717 NPI number — ANGELINA BISSONNETTE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BISSONNETTE
Provider First Name:
ANGELINA
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:
LUNDIN
Provider Other First Name:
ANGELINA
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:
1639471717
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/11/2017
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:
444 CENTER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANCHESTER
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06040-3926
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-646-3888
Provider Business Practice Location Address Fax Number:
860-645-4132
Provider Enumeration Date:
11/23/2010

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: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1300881 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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