Healthcare Provider Details

I. General information

NPI: 1598714701
Provider Name (Legal Business Name): HANNA KACKIELO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 06/19/2020
Certification Date: 06/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 TOWNE PARK PLZ
NORWICH CT
06360-2247
US

IV. Provider business mailing address

1 TOWNE PARK PLZ
NORWICH CT
06360-2247
US

V. Phone/Fax

Practice location:
  • Phone: 860-887-0010
  • Fax: 860-887-0178
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number037461
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number037461
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: