Basic Information
Provider Information | |||||||||
NPI: | 1700802063 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RICCI | ||||||||
FirstName: | AUDRA | ||||||||
MiddleName: | P | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | FLINT | ||||||||
OtherFirstName: | AUDRA | ||||||||
OtherMiddleName: | P | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 73 NEWTON RD | ||||||||
Address2: | STE 101 | ||||||||
City: | PLAISTOW | ||||||||
State: | NH | ||||||||
PostalCode: | 038652424 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9783887272 | ||||||||
FaxNumber: | 9783887373 | ||||||||
Practice Location | |||||||||
Address1: | 485 HARTFORD RD | ||||||||
Address2: | STE B | ||||||||
City: | MANCHESTER | ||||||||
State: | CT | ||||||||
PostalCode: | 060404869 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8606461561 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/13/2006 | ||||||||
LastUpdateDate: | 12/28/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 005548 | CT | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 650001233 | 01 | CT | MEDICARE PTAN | OTHER | ANTHEM | 01 |   | 080005548CT11 | OTHER | 004210457 | 05 | CT |   | MEDICAID | 5511600 | 01 |   | AETNA INDIV PIN | OTHER |