Healthcare Provider Details

I. General information

NPI: 1396733671
Provider Name (Legal Business Name): MELANIE J KIROUAC PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MELANIE J KRUPA PA

II. Dates (important events)

Enumeration Date: 10/11/2005
Last Update Date: 09/18/2025
Certification Date: 09/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

538 LITCHFIELD ST STE 104
TORRINGTON CT
06790-6669
US

IV. Provider business mailing address

538 LITCHFIELD ST STE 104
TORRINGTON CT
06790-6669
US

V. Phone/Fax

Practice location:
  • Phone: 860-496-6257
  • Fax: 860-496-6219
Mailing address:
  • Phone: 860-496-6257
  • Fax: 860-496-6219

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5778
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA1772
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA1772
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: