Healthcare Provider Details

I. General information

NPI: 1649038613
Provider Name (Legal Business Name): KAITLIN CRUZ RN, CDOE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KAITLIN GAGNE RN, CDOE

II. Dates (important events)

Enumeration Date: 03/13/2024
Last Update Date: 07/15/2024
Certification Date: 07/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 ATWOOD ST
PROVIDENCE RI
02909-3410
US

IV. Provider business mailing address

375 ALLENS AVE
PROVIDENCE RI
02905-5010
US

V. Phone/Fax

Practice location:
  • Phone: 401-444-0590
  • Fax: 401-396-2084
Mailing address:
  • Phone: 401-444-0400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License NumberRN66114
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: