Healthcare Provider Details

I. General information

NPI: 1245462589
Provider Name (Legal Business Name): KELSEY EJZAK CAULFIELD PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS KELSEY ELIZABETH EJZAK

II. Dates (important events)

Enumeration Date: 08/20/2009
Last Update Date: 06/11/2025
Certification Date: 06/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

270 MAIN ST STE A
PORTLAND CT
06480-1836
US

IV. Provider business mailing address

28 CRESCENT ST
MIDDLETOWN CT
06457-3654
US

V. Phone/Fax

Practice location:
  • Phone: 860-358-5040
  • Fax:
Mailing address:
  • Phone: 860-358-4870
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2312
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: