Healthcare Provider Details

I. General information

NPI: 1942538913
Provider Name (Legal Business Name): AMY L KENEFICK FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2009
Last Update Date: 03/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

76 PALOMBA DR
ENFIELD CT
06082-3856
US

IV. Provider business mailing address

345 WHITNEY AVE
NEW HAVEN CT
06511-2348
US

V. Phone/Fax

Practice location:
  • Phone: 860-741-2197
  • Fax: 860-741-6824
Mailing address:
  • Phone: 203-752-2856
  • Fax: 203-752-8785

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number002219
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: