Healthcare Provider Details

I. General information

NPI: 1992058630
Provider Name (Legal Business Name): KRISTEN LEE VANWORMER RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2012
Last Update Date: 10/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 RAYMOND RD
AVON CT
06001-3629
US

IV. Provider business mailing address

6 RAYMOND RD
AVON CT
06001-3629
US

V. Phone/Fax

Practice location:
  • Phone: 860-944-9776
  • Fax: 860-735-6532
Mailing address:
  • Phone: 860-944-9776
  • Fax: 860-735-6532

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: