Provider Demographics
NPI:1285952267
Name:MCNALLY, NOVA
Entity type:Individual
Prefix:
First Name:NOVA
Middle Name:
Last Name:MCNALLY
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:PO BOX 706
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:CT
Mailing Address - Zip Code:06234-0706
Mailing Address - Country:US
Mailing Address - Phone:860-779-9308
Mailing Address - Fax:
Practice Address - Street 1:159 WAUREGAN RD
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:CT
Practice Address - Zip Code:06234-1925
Practice Address - Country:US
Practice Address - Phone:860-779-9308
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-14
Last Update Date:2010-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002851174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist