Provider Demographics
NPI:1295841682
Name:HEADLEY, ANNETTE LUPINACCI (MD)
Entity Type:Individual
Prefix:
First Name:ANNETTE
Middle Name:LUPINACCI
Last Name:HEADLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56 WHITEHALL AVENUE
Mailing Address - Street 2:
Mailing Address - City:MYSTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06355
Mailing Address - Country:US
Mailing Address - Phone:860-536-1354
Mailing Address - Fax:860-536-7043
Practice Address - Street 1:56 WHITEHALL AVENUE
Practice Address - Street 2:
Practice Address - City:MYSTIC
Practice Address - State:CT
Practice Address - Zip Code:06355
Practice Address - Country:US
Practice Address - Phone:860-536-1354
Practice Address - Fax:860-536-7043
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2010-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT034245207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001342451Medicaid
F96443Medicare UPIN
CT070000368Medicare ID - Type Unspecified