Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LP0808X | Nurse Practitioner - Psychiatric/Mental Health | 069995-23 | NH |
NPI | 1023675824 |
---|---|
Provider Name | Alex Reardon |
First Address | Derry, NH 03038-1505 |
Second Address | Derry, NH 03038-1505 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/05/2019 |
Last Update Date | 23/09/2019 |