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General NPI Number Information
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NPI Number | 1265456347
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Entity Type | Individual
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Provider Name | KATHRYN E JACK APRN
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Gender | Female
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Dates
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Enumeration Date | 07/26/2006
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Last Update Date | 11/05/2013
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Provider Practice Location Address
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Address Line | 455 LEWIS AVE SUITE 106
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City | MERIDEN
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State | CT
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Zip | 06451-2121
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Country | US
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Telephone | 203-886-0036
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Fax | 203-886-0072
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Provider Business Mailing Address
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Address Line | 2139 SILAS DEANE HWY
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City | ROCKY HILL
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State | CT
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Zip | 06067-2336
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Country | US
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Telephone | 860-257-4131
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Fax | 860-257-4519
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 002455
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License Number State | CT
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Taxonomy #2
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Taxonomy Code | 363LA2200X
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Taxonomy Name | Adult Health Nurse Practitioner
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License Number | 002455
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License Number State | CT
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Taxonomy #3
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 002455
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License Number State | CT
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