1366168924 NPI number — KAITLIN ELIZABETH KORNGIEBEL PHARM.D.

Table of content: KAITLIN ELIZABETH KORNGIEBEL PHARM.D. (NPI 1366168924)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366168924 NPI number — KAITLIN ELIZABETH KORNGIEBEL PHARM.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KORNGIEBEL
Provider First Name:
KAITLIN
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHARM.D.
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:
1366168924
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/17/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 REGAN RD APT 33B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VERNON ROCKVILLE
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06066-2843
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-816-5550
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
22 WINDSOR AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VERNON ROCKVILLE
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06066-2439
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-870-6765
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/17/2022

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: 183500000X , with the licence number:  15742 , 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)





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