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NPI Code Detail

MEDICARE: SUSADA INTHAVONG APRN

MEDICARE: SUSADA INTHAVONG APRN
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363L00000XNurse Practitioner003968CT

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1003968OTHERCTSTATE LICENSE

General Provider Information

NPI Number : 1275770398
Entity Type Code : Individual
Provider Name (Legal Business Name) : SUSADA INTHAVONG APRN
Provider Business Mailing Address
First Line : 29 NAEK RD
Second Line : SUITE 5
City : VERNON
State : CT
Zip : 06066-3942
Country : US
Telephone Number : 860-872-2289
Fax Number : 860-896-1425
Provider Business Practice Location Address
First Line : 1504 SULLIVAN AVE
Second Line :
City : SOUTH WINDSOR
State : CT
Zip : 06074-2711
Country : US
Telephone Number : 860-644-1523
Fax Number : 860-648-9468
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/12/2009
Last Update Date : 01/12/2009

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