Healthcare Provider Details

I. General information

NPI: 1063797934
Provider Name (Legal Business Name): KENNETH PASSAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2011
Last Update Date: 09/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1680 ALBANY AVE
HARTFORD CT
06105-1001
US

IV. Provider business mailing address

1680 ALBANY AVE
HARTFORD CT
06105-1001
US

V. Phone/Fax

Practice location:
  • Phone: 860-236-4511
  • Fax: 860-296-1071
Mailing address:
  • Phone: 860-236-4511
  • Fax: 860-296-1071

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberE53156
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: