Healthcare Provider Details

I. General information

NPI: 1497944425
Provider Name (Legal Business Name): KERRY ROSE STEPHENSON APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2007
Last Update Date: 02/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

575 MAIN ST FL 2 ATTN: CREDENTIALING DPT
MIDDLETOWN CT
06457-2845
US

IV. Provider business mailing address

1 SHAWS CV
NEW LONDON CT
06320-4902
US

V. Phone/Fax

Practice location:
  • Phone: 860-347-6971
  • Fax:
Mailing address:
  • Phone: 860-447-8304
  • Fax: 860-443-8720

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number003654
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: