Provider Demographics
NPI:1497210058
Name:NGUYEN, AVY
Entity type:Individual
Prefix:
First Name:AVY
Middle Name:
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 SYCAWAY ST
Mailing Address - Street 2:
Mailing Address - City:WEST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06516-1222
Mailing Address - Country:US
Mailing Address - Phone:203-690-8011
Mailing Address - Fax:
Practice Address - Street 1:251 TURN OF RIVER RD
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06905-1320
Practice Address - Country:US
Practice Address - Phone:203-916-5409
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-07
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5143225X00000X, 225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT078290197OtherDRIVER LICENSE