1700264090 NPI number — ANGIE BOLDUC

Table of content: ANGIE BOLDUC (NPI 1700264090)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700264090 NPI number — ANGIE BOLDUC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOLDUC
Provider First Name:
ANGIE
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:
VERRANEAULT
Provider Other First Name:
ANGIE
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:
1700264090
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/15/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2 WATERSIDE XING STE 401
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:
06095-1588
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:
391 POMFRET ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PUTNAM
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06260-1852
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-963-4971
Provider Business Practice Location Address Fax Number:
860-963-4979
Provider Enumeration Date:
05/07/2015

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: 101Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 164W00000X , with the licence number: 038592 , 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)





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