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General NPI Number Information
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NPI Number | 1568772242
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Entity Type | Organization
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Legal Business Name | ANNETTE L HEADLEY MD LLC
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Dates
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Enumeration Date | 10/15/2010
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Last Update Date | 11/09/2010
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Provider Practice Location Address
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Address Line | 56 WHITEHALL AVE
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City | MYSTIC
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State | CT
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Zip | 06355-1978
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Country | US
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Telephone | 860-536-1354
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Fax | 860-536-7043
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Provider Business Mailing Address
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Address Line | 56 WHITEHALL AVE
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City | MYSTIC
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State | CT
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Zip | 06355-1978
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Country | US
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Telephone | 860-536-1354
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Fax | 860-536-7043
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Authorized Official
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Title or Position | PROPRIETOR/PHYSICIAN
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Name | DR. ANNETTE L HEADLEY
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Credential | MD
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Telephone | 860-536-1354
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | 034245
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License Number State | CT
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