1467557116 NPI number — MRS. HEATHER MARY SHATTUCK PTMS

Table of content: MRS. HEATHER MARY SHATTUCK PTMS (NPI 1467557116)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467557116 NPI number — MRS. HEATHER MARY SHATTUCK PTMS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHATTUCK
Provider First Name:
HEATHER
Provider Middle Name:
MARY
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PTMS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KENYON
Provider Other First Name:
HEATHER
Provider Other Middle Name:
MARY
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PTMS
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1467557116
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
35 COUNTY ROUTE 7
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GOUVERNEUR
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13642
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
315-578-2849
Provider Business Mailing Address Fax Number:
315-782-6612

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
GAFFNEY DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WATERTOWN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-788-2730
Provider Business Practice Location Address Fax Number:
315-782-6612
Provider Enumeration Date:
09/14/2006

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: 225100000X , with the licence number:  0226661 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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