Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 225000000X | Orthotic Fitter | ||
Y | 225100000X | Physical Therapist | 003621 | CT |
NPI | 1700064979 |
---|---|
Provider Name | Roberta Nole |
First Address | Middlebury, CT 06762-1830 |
Second Address | Middlebury, CT 06762-1830 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/02/2008 |
Last Update Date | 30/01/2009 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
004137338 | (05) | CT |
12DME0603CT01 | ANTHEM BLUE CROSS BLUE SHIELD (01) | CT |