Healthcare Provider Details

I. General information

NPI: 1225534936
Provider Name (Legal Business Name): VICKY KATHERINE YIANNOULIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2018
Last Update Date: 09/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 WILLARD AVE
NEWINGTON CT
06111
US

IV. Provider business mailing address

555 WILLARD AVE
NEWINGTON CT
06111-2631
US

V. Phone/Fax

Practice location:
  • Phone: 860-666-6951
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3072
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: