Healthcare Provider Details

I. General information

NPI: 1255990578
Provider Name (Legal Business Name): CAITLIN PATRICIA SOUCY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2019
Last Update Date: 08/13/2024
Certification Date: 08/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47 JOLLEY DR
BLOOMFIELD CT
06002-3092
US

IV. Provider business mailing address

71 OLD MEADOW PLAIN RD
WEATOGUE CT
06089-9771
US

V. Phone/Fax

Practice location:
  • Phone: 860-243-3020
  • Fax:
Mailing address:
  • Phone: 860-371-5711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number004764
License Number StateCT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: