Provider Demographics
NPI:1932609740
Name:EASTERLIN, AMY L (LO)
Entity Type:Individual
Prefix:MS
First Name:AMY
Middle Name:L
Last Name:EASTERLIN
Suffix:
Gender:F
Credentials:LO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 WAWECUS ST STE 105
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360-2173
Mailing Address - Country:US
Mailing Address - Phone:860-886-0161
Mailing Address - Fax:860-889-5999
Practice Address - Street 1:79 WAWECUS ST STE 105
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360-2173
Practice Address - Country:US
Practice Address - Phone:860-886-0161
Practice Address - Fax:860-889-5999
Is Sole Proprietor?:No
Enumeration Date:2018-02-19
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001620156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician