1548273485 NPI number — KIMBERLY LAQUERRE CUNNINGHAM MSPT

Table of content: KIMBERLY LAQUERRE CUNNINGHAM MSPT (NPI 1548273485)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548273485 NPI number — KIMBERLY LAQUERRE CUNNINGHAM MSPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CUNNINGHAM
Provider First Name:
KIMBERLY
Provider Middle Name:
LAQUERRE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LAQUERRE
Provider Other First Name:
KIMBERLY
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MSPT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1548273485
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/21/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7 ELM ST
Provider Second Line Business Mailing Address:
SUITE 204
Provider Business Mailing Address City Name:
ENFIELD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06082-3669
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-741-2242
Provider Business Mailing Address Fax Number:
860-741-2248

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7 ELM ST
Provider Second Line Business Practice Location Address:
SUITE 204
Provider Business Practice Location Address City Name:
ENFIELD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06082-3669
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-741-2242
Provider Business Practice Location Address Fax Number:
860-741-2248
Provider Enumeration Date:
08/14/2006

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:  007675 , 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)

  • Identifier: 004251211 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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