Healthcare Provider Details

I. General information

NPI: 1952377145
Provider Name (Legal Business Name): KATHLEEN M DEMERS APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2006
Last Update Date: 01/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 HARTFORD PIKE
DAYVILLE CT
06241-2159
US

IV. Provider business mailing address

320 POMFRET ST
PUTNAM CT
06260-1836
US

V. Phone/Fax

Practice location:
  • Phone: 860-779-6068
  • Fax: 860-779-7597
Mailing address:
  • Phone: 860-928-6541
  • Fax: 860-963-6091

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number000632
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number000632
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: