Healthcare Provider Details

I. General information

NPI: 1386123602
Provider Name (Legal Business Name): DEBORAH VATHALLY APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2018
Last Update Date: 08/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

396 HIGH ST STE 1
SOMERSWORTH NH
03878-1427
US

IV. Provider business mailing address

396 HIGH ST STE 1
SOMERSWORTH NH
03878-1427
US

V. Phone/Fax

Practice location:
  • Phone: 603-692-6066
  • Fax: 603-692-4815
Mailing address:
  • Phone: 603-692-6066
  • Fax: 603-692-4815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number056540-23
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: