Healthcare Provider Details

I. General information

NPI: 1861012015
Provider Name (Legal Business Name): ZACHARY AUSTIN KIETZMAN NP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: ZACHARY AUSTIN HILL NP-C

II. Dates (important events)

Enumeration Date: 04/17/2020
Last Update Date: 08/20/2023
Certification Date: 08/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 FARM GLEN BLVD
FARMINGTON CT
06030-1285
US

IV. Provider business mailing address

87B OLIVE ST
NEW HAVEN CT
06511-6913
US

V. Phone/Fax

Practice location:
  • Phone: 803-629-4134
  • Fax:
Mailing address:
  • Phone: 803-629-4134
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberRN236642
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number12068
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberRN236642
License Number StateGA
# 4
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number12068
License Number StateCT
# 5
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number209707
License Number StateCT
# 6
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN236642
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: