Healthcare Provider Details

I. General information

NPI: 1073717351
Provider Name (Legal Business Name): NORTHWEST ALLERGY, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2007
Last Update Date: 09/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

72A PARK LANE RD
NEW MILFORD CT
06776-2325
US

IV. Provider business mailing address

PO BOX 1317
NEW MILFORD CT
06776-1317
US

V. Phone/Fax

Practice location:
  • Phone: 860-354-0464
  • Fax: 860-350-3268
Mailing address:
  • Phone: 860-354-0464
  • Fax: 860-350-3268

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number033471
License Number StateCT

VIII. Authorized Official

Name: DR. PAMELA LAURIE KWITTKEN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 860-354-0464