Healthcare Provider Details

I. General information

NPI: 1467484022
Provider Name (Legal Business Name): KELLY LINDQUIST PA C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 06/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 MAIN STREET
UNIONVILLE CT
06085
US

IV. Provider business mailing address

101 MAIN STREET
UNIONVILLE CT
06085
US

V. Phone/Fax

Practice location:
  • Phone: 860-673-6124
  • Fax: 860-673-3290
Mailing address:
  • Phone: 860-673-6124
  • Fax: 860-673-3290

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number001518
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: