Healthcare Provider Details

I. General information

NPI: 1295048502
Provider Name (Legal Business Name): KELLY C. HANRETTA D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2010
Last Update Date: 04/15/2026
Certification Date: 04/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 YORK ST
NEW HAVEN CT
06510-3220
US

IV. Provider business mailing address

20 YORK ST
NEW HAVEN CT
06510-3220
US

V. Phone/Fax

Practice location:
  • Phone: 203-688-4748
  • Fax: 203-688-4740
Mailing address:
  • Phone: 203-688-4748
  • Fax: 203-688-4740

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number67486
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberDO01102
License Number StateRI
# 3
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number269430
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25MB08792600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: