Healthcare Provider Details

I. General information

NPI: 1326836305
Provider Name (Legal Business Name): BABU RAM KHATIWADA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2025
Last Update Date: 06/14/2026
Certification Date: 06/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 BURBAN DR
BRANFORD CT
06405-4003
US

IV. Provider business mailing address

109 BURBAN DR
BRANFORD CT
06405-4003
US

V. Phone/Fax

Practice location:
  • Phone: 203-825-5964
  • Fax:
Mailing address:
  • Phone: 203-824-7959
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number16836
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: