1952110587 NPI number — KARLA TATIANA GUISHARD FUENTES DPT

Table of content: KARLA TATIANA GUISHARD FUENTES DPT (NPI 1952110587)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952110587 NPI number — KARLA TATIANA GUISHARD FUENTES DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GUISHARD FUENTES
Provider First Name:
KARLA
Provider Middle Name:
TATIANA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPT
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:
1952110587
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/07/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1105
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ENFIELD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06083-1105
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
475-655-0359
Provider Business Mailing Address Fax Number:
203-504-7700

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1336 W MAIN ST STE 1B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WATERBURY
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06708-3122
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-437-7229
Provider Business Practice Location Address Fax Number:
203-504-7700
Provider Enumeration Date:
01/07/2025

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:  14721 , 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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