Healthcare Provider Details

I. General information

NPI: 1962772939
Provider Name (Legal Business Name): KIMBERLY L BELLAVANCE MPAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2012
Last Update Date: 02/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 WOODLAND ST SURGERY DEPT.
HARTFORD CT
06105-1208
US

IV. Provider business mailing address

1000 ASYLUM AVE SUITE 2109A
HARTFORD CT
06105-1770
US

V. Phone/Fax

Practice location:
  • Phone: 860-714-4694
  • Fax: 860-714-8096
Mailing address:
  • Phone: 860-714-6581
  • Fax: 860-714-8311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number2714
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: