Provider Demographics
NPI:1114115706
Name:PRACTITIONER SUPPORT SERVICES LLP
Entity Type:Organization
Organization Name:PRACTITIONER SUPPORT SERVICES LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:V
Authorized Official - Last Name:PENRY
Authorized Official - Suffix:
Authorized Official - Credentials:NP-C
Authorized Official - Phone:203-518-2124
Mailing Address - Street 1:PO BOX 4058
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:CT
Mailing Address - Zip Code:06468-9998
Mailing Address - Country:US
Mailing Address - Phone:203-518-2124
Mailing Address - Fax:888-496-0267
Practice Address - Street 1:324 ELM ST STE 202B
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:CT
Practice Address - Zip Code:06468-2284
Practice Address - Country:US
Practice Address - Phone:203-518-2124
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-09
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Multi-Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004248870Medicaid
CT004248870Medicaid