Healthcare Provider Details

I. General information

NPI: 1437193273
Provider Name (Legal Business Name): LUCINDA L HAUTANIEMI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 04/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

154 MAIN ST
OLD SAYBROOK CT
06475-2373
US

IV. Provider business mailing address

28 CRESCENT ST
MIDDLETOWN CT
06457-3654
US

V. Phone/Fax

Practice location:
  • Phone: 860-395-1212
  • Fax: 860-358-8654
Mailing address:
  • Phone: 860-358-4820
  • Fax: 860-358-8661

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number025707
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: