Healthcare Provider Details

I. General information

NPI: 1962919605
Provider Name (Legal Business Name): KATHARINA ERNST-SIXTO LICENSED OPTICIAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2018
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

495 HAWLEY LN
STRATFORD CT
06614-1514
US

IV. Provider business mailing address

495 HAWLEY LN
STRATFORD CT
06614-1514
US

V. Phone/Fax

Practice location:
  • Phone: 203-375-5819
  • Fax: 203-377-4337
Mailing address:
  • Phone: 203-375-5819
  • Fax: 203-377-4337

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code156FX1800X
TaxonomyOptician
License Number001623
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number001623
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: