1114673332 NPI number — MARY T VANNORTWICK DCN, RDN

Table of content: MARY T VANNORTWICK DCN, RDN (NPI 1114673332)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114673332 NPI number — MARY T VANNORTWICK DCN, RDN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VANNORTWICK
Provider First Name:
MARY
Provider Middle Name:
T
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DCN, RDN
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:
1114673332
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/25/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
SIA MEDICAL PC
Provider Second Line Business Mailing Address:
176 E. 71ST STREET, #10B
Provider Business Mailing Address City Name:
NY
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10021-5159
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-778-1126
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
FLYTE MEDICAL PC
Provider Second Line Business Practice Location Address:
69 GROVE STREET
Provider Business Practice Location Address City Name:
NEW CANAAN
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06840-5325
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
844-359-8363
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/25/2022

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: 133VN1201X , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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