Healthcare Provider Details

I. General information

NPI: 1013469394
Provider Name (Legal Business Name): MRS. KRISTEN DENISE BURNHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2016
Last Update Date: 11/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

265 ELLINGTON RD
EAST HARTFORD CT
06108-1176
US

IV. Provider business mailing address

265 ELLINGTON RD
EAST HARTFORD CT
06108-1176
US

V. Phone/Fax

Practice location:
  • Phone: 860-528-1359
  • Fax:
Mailing address:
  • Phone: 860-528-1359
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number093001
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code163WW0101X
TaxonomyAmbulatory Women's Health Care Registered Nurse
License Number093001
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: