Healthcare Provider Details

I. General information

NPI: 1720437502
Provider Name (Legal Business Name): JENNIFER NOONAN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2016
Last Update Date: 06/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 JEFFERSON BLVD
WARWICK RI
02888-3847
US

IV. Provider business mailing address

55 HATCHETTS HILL RD
OLD LYME CT
06371-1534
US

V. Phone/Fax

Practice location:
  • Phone: 800-370-3651
  • Fax: 877-515-7147
Mailing address:
  • Phone: 800-370-3651
  • Fax: 877-515-7147

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA00873
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: