Healthcare Provider Details

I. General information

NPI: 1992232813
Provider Name (Legal Business Name): SIMONE V KENNEDY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SIMONE V GORSKI PA-C

II. Dates (important events)

Enumeration Date: 05/23/2017
Last Update Date: 12/18/2024
Certification Date: 12/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

435 LEWIS AVE STE 104
MERIDEN CT
06451-2101
US

IV. Provider business mailing address

1290 SILAS DEANE HWY
WETHERSFIELD CT
06109-4337
US

V. Phone/Fax

Practice location:
  • Phone: 203-694-5200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number003833
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: