Basic Information
Provider Information | |||||||||
NPI: | 1467114611 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GUNNESON | ||||||||
FirstName: | BRITTNEY | ||||||||
MiddleName: | ANN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 764 DEVONWOOD DR | ||||||||
Address2: |   | ||||||||
City: | CHESHIRE | ||||||||
State: | CT | ||||||||
PostalCode: | 064101552 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2036459488 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 800 BOSTON POST ROAD | ||||||||
Address2: |   | ||||||||
City: | GUILFORD | ||||||||
State: | CT | ||||||||
PostalCode: | 06437 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8779253637 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/05/2021 | ||||||||
LastUpdateDate: | 02/28/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/28/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 5558 | CT | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 363AS0400X |   |   | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AM0700X |   |   | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.