1093963175 NPI number — SUSAN Y LATTANZI N.P.

Table of content: SUSAN Y LATTANZI N.P. (NPI 1093963175)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093963175 NPI number — SUSAN Y LATTANZI N.P.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LATTANZI
Provider First Name:
SUSAN
Provider Middle Name:
Y
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
N.P.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
YETMAN
Provider Other First Name:
SUSAN
Provider Other Middle Name:
JEANNE
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:
1093963175
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/23/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 STAFFORD STREET
Provider Second Line Business Mailing Address:
SUITES 101, 154 & 161
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01104-2431
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
413-732-1928
Provider Business Mailing Address Fax Number:
413-734-1716

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 STAFFORD STREET
Provider Second Line Business Practice Location Address:
SUITES 101, 154 & 161
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01104-2431
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
413-732-1928
Provider Business Practice Location Address Fax Number:
413-734-1716
Provider Enumeration Date:
09/03/2008

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: 363LA2100X , with the licence number:  168570 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 110087924A , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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