Healthcare Provider Details

I. General information

NPI: 1669483533
Provider Name (Legal Business Name): KAYLEEN BASTIAANSE APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 10/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

538 LITCHFIELD ST SUITE 103
TORRINGTON CT
06790-6669
US

IV. Provider business mailing address

4 FARM SPRINGS RD PROHEALTH PHYSICIANS
FARMINGTON CT
06032-2573
US

V. Phone/Fax

Practice location:
  • Phone: 860-489-5148
  • Fax: 860-489-4752
Mailing address:
  • Phone: 860-284-5200
  • Fax: 860-284-5333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number001974
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: