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General NPI Number Information
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NPI Number | 1699851568
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Entity Type | Individual
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Provider Name | EILEEN MARY TICHY PAC RD
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Gender | Female
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Dates
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Enumeration Date | 10/31/2006
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Last Update Date | 04/01/2011
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Provider Practice Location Address
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Address Line | 2 CHURCH ST S SUITE 401
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City | NEW HAVEN
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State | CT
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Zip | 06519-1717
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Country | US
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Telephone | 203-785-5192
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Fax |
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Provider Business Mailing Address
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Address Line | 155 TALCOTT RD
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City | GUILFORD
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State | CT
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Zip | 06437-5001
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Country | US
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Telephone | 203-204-2398
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 001042
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License Number State | CT
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Taxonomy #2
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Taxonomy Code | 133V00000X
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Taxonomy Name | Registered Dietitian
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License Number | PENDING
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License Number State | CT
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