=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356729487
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELSEY WOOD P.A.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/08/2015
-----------------------------------------------------
Last Update Date | 06/08/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 574 MIDDLE TURNPIKE EAST KELSEY WOOD
-----------------------------------------------------
City | MANCHESTER
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06040-3730
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-646-4334
-----------------------------------------------------
Fax | 860-646-7020
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 200 TECHNOLOGY DR
-----------------------------------------------------
City | HOOKSETT
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03106-2504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-232-8925
-----------------------------------------------------
Fax | 603-647-8593
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 1273
-----------------------------------------------------
License Number State | NH
-----------------------------------------------------