Basic Information
| Provider Information | |||||||||
| NPI: | 1740361179 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PONICHTERA | ||||||||
| FirstName: | PAMELA | ||||||||
| MiddleName: | BOND | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | A.P.R.N. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8 COBBS RD | ||||||||
| Address2: | |||||||||
| City: | WEST HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061071401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8605212430 | ||||||||
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| Practice Location | |||||||||
| Address1: | 500 ALBANY AVENUE | ||||||||
| Address2: | PEDIATRIC CLINIC | ||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602499625 | ||||||||
| FaxNumber: | 8608081542 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2006 | ||||||||
| LastUpdateDate: | 11/22/2011 | ||||||||
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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 | 363LP0200X | 001273 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 004151916 | 05 | CT | MEDICAID |