Healthcare Provider Details

I. General information

NPI: 1245213461
Provider Name (Legal Business Name): TERESA ANN PONN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TERESA ANN BICKNELL

II. Dates (important events)

Enumeration Date: 11/22/2005
Last Update Date: 04/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

185 QUEEN CITY AVE
MANCHESTER NH
03101-7100
US

IV. Provider business mailing address

185 QUEEN CITY AVE ELLIOT BREAST HEALTH CENTER
MANCHESTER NH
03101-7100
US

V. Phone/Fax

Practice location:
  • Phone: 603-668-3067
  • Fax: 603-668-0164
Mailing address:
  • Phone: 603-668-3067
  • Fax: 603-668-0164

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number13176
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: