Basic Information
| Provider Information | |||||||||
| NPI: | 1023412400 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KACIK | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | APRN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ANDRADE | ||||||||
| OtherFirstName: | STEPHANIE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherNameSuffix: | |||||||||
| OtherCredential: | APRN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 20 YORK ST | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065103220 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 20 YORK ST | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065103220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2032004363 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2014 | ||||||||
| LastUpdateDate: | 11/07/2014 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 5954 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LG0600X | 5954 | CT | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
No ID Information.