=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730690546
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN T PALMA PMHNP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/19/2017
-----------------------------------------------------
Last Update Date | 10/19/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2969 WHITNEY AVE
-----------------------------------------------------
City | HAMDEN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06518-2556
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-691-7634
-----------------------------------------------------
Fax | 203-859-5437
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 35 PRINZ CT
-----------------------------------------------------
City | CHESHIRE
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06410-2971
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-323-0349
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 7335
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------