1932287893 NPI number — HOLLY ROXANNE KINNELL-RUST FNP

Table of content: HOLLY ROXANNE KINNELL-RUST FNP (NPI 1932287893)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932287893 NPI number — HOLLY ROXANNE KINNELL-RUST FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KINNELL-RUST
Provider First Name:
HOLLY
Provider Middle Name:
ROXANNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1932287893
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/15/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
320 POMFRET ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PUTNAM
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06260-1836
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-963-6371
Provider Business Mailing Address Fax Number:
860-963-6413

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
320 POMFRET ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PUTNAM
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06260-1836
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-963-6371
Provider Business Practice Location Address Fax Number:
860-963-6413
Provider Enumeration Date:
11/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  191964 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 2010026851 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 7023 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1932287893 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00859525 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 008073029 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 184085758 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 431560263 . This is a "TRICARE WEST" identifier . This identifiers is of the category "OTHER".




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