Provider Demographics
NPI:1073949509
Name:POUPON, MARY ALICE (NPP)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:ALICE
Last Name:POUPON
Suffix:
Gender:F
Credentials:NPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 SPLIT ROCK RD
Mailing Address - Street 2:
Mailing Address - City:NEWTOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06470-2456
Mailing Address - Country:US
Mailing Address - Phone:203-364-7000
Mailing Address - Fax:
Practice Address - Street 1:23 SPLIT ROCK RD
Practice Address - Street 2:
Practice Address - City:NEWTOWN
Practice Address - State:CT
Practice Address - Zip Code:06470-2456
Practice Address - Country:US
Practice Address - Phone:203-364-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-16
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002708363LP0808X, 364SP0807X
NY7903263363LP0808X, 364SP0807X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No364SP0807XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Child & Adolescent