1730320573 NPI number — MRS. ANDREA LYN PANACCIONE RD

Table of content: MRS. ANDREA LYN PANACCIONE RD (NPI 1730320573)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730320573 NPI number — MRS. ANDREA LYN PANACCIONE RD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PANACCIONE
Provider First Name:
ANDREA
Provider Middle Name:
LYN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
STRUM
Provider Other First Name:
ANDREA
Provider Other Middle Name:
LYN
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
RD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1730320573
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/06/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
774 NEWMAN SPRINGS RD
Provider Second Line Business Mailing Address:
PO BOX 351
Provider Business Mailing Address City Name:
LINCROFT
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07738-1608
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
732-687-0791
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
95 SHELBERN DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LINCROFT
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07738-1326
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
732-687-0791
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/06/2009

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: 133V00000X , with the licence number:  000910110 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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