1841833159 NPI number — MRS. SHANTAE ALICIA FYFFE-SIMPSON

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841833159 NPI number — MRS. SHANTAE ALICIA FYFFE-SIMPSON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FYFFE-SIMPSON
Provider First Name:
SHANTAE
Provider Middle Name:
ALICIA
Provider Name Prefix Text:
MRS.
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:
FYFFE
Provider Other First Name:
SHANTAE
Provider Other Middle Name:
ALICIA
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1841833159
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/20/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 HEAD OF MEADOW RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWTOWN
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06470-1788
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
917-543-4521
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 HEAD OF MEADOW RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWTOWN
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06470-1788
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
917-543-4521
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/21/2019

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: 104100000X , with the licence number:  6889 , 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)





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