Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | 001763 | CT |
NPI | 1003321985 |
---|---|
Provider Name | Holly J Gudeahn |
First Address | Putnam, CT 06260-2424 |
Second Address | Putnam, CT 06260-2424 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 13/12/2017 |
Last Update Date | 13/12/2017 |