Basic Information
| Provider Information | |||||||||
| NPI: | 1245213461 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PONN | ||||||||
| FirstName: | TERESA | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BICKNELL | ||||||||
| OtherFirstName: | TERESA | ||||||||
| OtherMiddleName: | ANN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 185 QUEEN CITY AVE | ||||||||
| Address2: | ELLIOT BREAST HEALTH CENTER | ||||||||
| City: | MANCHESTER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 031017100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036683067 | ||||||||
| FaxNumber: | 6036680164 | ||||||||
| Practice Location | |||||||||
| Address1: | 185 QUEEN CITY AVE | ||||||||
| Address2: | |||||||||
| City: | MANCHESTER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 031017100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036683067 | ||||||||
| FaxNumber: | 6036680164 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2005 | ||||||||
| LastUpdateDate: | 04/13/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 13176 | NH | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 30206042 | 05 | NH | MEDICAID |