Provider Demographics
NPI:1700802063
Name:RICCI, AUDRA P (PT)
Entity Type:Individual
Prefix:
First Name:AUDRA
Middle Name:P
Last Name:RICCI
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:AUDRA
Other - Middle Name:P
Other - Last Name:FLINT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:73 NEWTON RD
Mailing Address - Street 2:STE 101
Mailing Address - City:PLAISTOW
Mailing Address - State:NH
Mailing Address - Zip Code:03865-2424
Mailing Address - Country:US
Mailing Address - Phone:978-388-7272
Mailing Address - Fax:978-388-7373
Practice Address - Street 1:485 HARTFORD RD
Practice Address - Street 2:STE B
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040-4869
Practice Address - Country:US
Practice Address - Phone:860-646-1561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2016-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT005548225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT650001233OtherMEDICARE PTAN
ANTHEMOther080005548CT11
CT004210457Medicaid
5511600OtherAETNA INDIV PIN