Healthcare Provider Details

I. General information

NPI: 1225581937
Provider Name (Legal Business Name): KRISTAN BROWN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2016
Last Update Date: 06/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

490 BLUE HILLS AVE
HARTFORD CT
06112
US

IV. Provider business mailing address

490 BLUE HILLS AVE
HARTFORD CT
06112
US

V. Phone/Fax

Practice location:
  • Phone: 860-714-2647
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number12.006606
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: