Healthcare Provider Details

I. General information

NPI: 1033748975
Provider Name (Legal Business Name): ANXHELA KULLA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2020
Last Update Date: 07/05/2022
Certification Date: 07/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1981 E MAIN ST UNIT 2
WATERBURY CT
06705-1853
US

IV. Provider business mailing address

1981 E MAIN ST UNIT 2
WATERBURY CT
06705-1853
US

V. Phone/Fax

Practice location:
  • Phone: 203-709-5520
  • Fax:
Mailing address:
  • Phone: 203-709-5520
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number5086
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: