Healthcare Provider Details

I. General information

NPI: 1518885474
Provider Name (Legal Business Name): KEVIN FASULO RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

80 SEYMOUR ST
HARTFORD CT
06106-3315
US

IV. Provider business mailing address

22B POND MEADOW RD
IVORYTON CT
06442-1168
US

V. Phone/Fax

Practice location:
  • Phone: 860-545-5000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number209589
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: