=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609059286
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SONYA LISA MARSHALL DPM
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/06/2007
-----------------------------------------------------
Last Update Date | 12/09/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 85 POHEGANUT DR
-----------------------------------------------------
City | GROTON
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06340-3252
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-437-3737
-----------------------------------------------------
Fax | 860-437-0530
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 85 POHEGANUT DR
-----------------------------------------------------
City | GROTON
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06340-3252
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-437-3737
-----------------------------------------------------
Fax | 860-437-0530
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number | 871
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | CT871
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------