MEDICARE: KENIA GONDEK APRN

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	363LF0000X	Family Nurse Practitioner	12919	CT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1912596602
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENIA GONDEK APRN

Provider Business Mailing Address
First Line	:	6 NORTHWESTERN DR STE 201
Second Line	:
City	:	BLOOMFIELD
State	:	CT
Zip	:	06002-3416
Country	:	US
Telephone Number	:	860-242-6297
Fax Number	:

Provider Business Practice Location Address
First Line	:	6 NORTHWESTERN DR STE 201
Second Line	:
City	:	BLOOMFIELD
State	:	CT
Zip	:	06002-3416
Country	:	US
Telephone Number	:	860-242-6297
Fax Number	:

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

Provider Enumeration Date	:	01/16/2021
Last Update Date	:	05/21/2024

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