Healthcare Provider Details

I. General information

NPI: 1811606163
Provider Name (Legal Business Name): CASSANDRA ANN VIGUE RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2022
Last Update Date: 11/15/2022
Certification Date: 09/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 BALABAN RD APT 303
COLCHESTER CT
06415-7100
US

IV. Provider business mailing address

12 BALABAN RD APT 303
COLCHESTER CT
06415-7100
US

V. Phone/Fax

Practice location:
  • Phone: 860-634-4641
  • Fax:
Mailing address:
  • Phone: 860-634-4641
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number59.002013
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86148038
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: