Healthcare Provider Details

I. General information

NPI: 1972571354
Provider Name (Legal Business Name): STANLEY LORENZ KOLESZAR RN CRNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2006
Last Update Date: 02/22/2024
Certification Date: 02/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 KENNEDY DR
PUTNAM CT
06260-1939
US

IV. Provider business mailing address

320 POMFRET STREET CSB 2
PUTNAM CT
06260-1836
US

V. Phone/Fax

Practice location:
  • Phone: 860-928-7704
  • Fax: 860-928-4092
Mailing address:
  • Phone: 860-928-6541
  • Fax: 860-963-6450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP010390
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: