MEDICARE: KELLYN MISSET ND, LAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171100000X	Acupuncturist	000718	CT
2	175F00000X	Naturopath	000616	CT

General Provider Information

NPI Number	:	1740534247
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLYN MISSET ND, LAC

Provider Business Mailing Address
First Line	:	755 MAIN ST STE 8B
Second Line	:
City	:	MONROE
State	:	CT
Zip	:	06468-2830
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	755 MAIN ST STE 8B
Second Line	:
City	:	MONROE
State	:	CT
Zip	:	06468-2830
Country	:	US
Telephone Number	:	203-304-6043
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/05/2012
Last Update Date	:	11/05/2020

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