Healthcare Provider Details

I. General information

NPI: 1407422934
Provider Name (Legal Business Name): APPLESEED PEDIATRIC AND ADOLESCENT MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2021
Last Update Date: 06/03/2021
Certification Date: 06/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 E MAIN ST
MIDDLETOWN CT
06457-3840
US

IV. Provider business mailing address

80 E MAIN ST
MIDDLETOWN CT
06457-3840
US

V. Phone/Fax

Practice location:
  • Phone: 860-200-1465
  • Fax: 860-200-3378
Mailing address:
  • Phone: 860-200-1465
  • Fax: 860-200-3378

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: NICHOLE LYNN KYCIA
Title or Position: OWNER
Credential: PA-C
Phone: 860-558-3177