Provider Demographics
NPI:1699490953
Name:LOMBARDI, MYRANDA NICOLE (HIS)
Entity type:Individual
Prefix:
First Name:MYRANDA
Middle Name:NICOLE
Last Name:LOMBARDI
Suffix:
Gender:F
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 PINE ST UNIT B
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:CT
Mailing Address - Zip Code:06010-6960
Mailing Address - Country:US
Mailing Address - Phone:860-506-3720
Mailing Address - Fax:860-506-3721
Practice Address - Street 1:72 PINE ST UNIT B
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010-6960
Practice Address - Country:US
Practice Address - Phone:860-506-3720
Practice Address - Fax:860-506-3721
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-10
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT482237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument SpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT482OtherHIS LICENSE