Healthcare Provider Details

I. General information

NPI: 1477969186
Provider Name (Legal Business Name): KRISTEN LEIGH EASEY WACKELIN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRISTEN LEIGH EASEY PA-C

II. Dates (important events)

Enumeration Date: 07/02/2014
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 ELM ST STE 201
ENFIELD CT
06082-3670
US

IV. Provider business mailing address

126 WOODRUFF RD
FARMINGTON CT
06032-2030
US

V. Phone/Fax

Practice location:
  • Phone: 860-636-2010
  • Fax:
Mailing address:
  • Phone: 941-284-3850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number6200
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9108005
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: