1780213488 NPI number — JULIA NICOLE VANASSE

Table of content: JULIA NICOLE VANASSE (NPI 1780213488)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780213488 NPI number — JULIA NICOLE VANASSE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VANASSE
Provider First Name:
JULIA
Provider Middle Name:
NICOLE
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:
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:
1780213488
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/03/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
960 MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRANFORD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06405-3730
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-488-6358
Provider Business Mailing Address Fax Number:
203-481-5327

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
960 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRANFORD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06405-3730
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-488-6358
Provider Business Practice Location Address Fax Number:
203-481-5327
Provider Enumeration Date:
04/04/2020

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 , with the licence number:  5072 , 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)