Basic Information
| Provider Information | |||||||||
| NPI: | 1114993987 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STURROCK | ||||||||
| FirstName: | KELLEY | ||||||||
| MiddleName: | LYN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 RETREAT AVE | ||||||||
| Address2: | STE. 201 | ||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061062528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602468568 | ||||||||
| FaxNumber: | 8607285076 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 RETREAT AVE | ||||||||
| Address2: | STE 201 | ||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061062528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602468568 | ||||||||
| FaxNumber: | 8607285076 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2006 | ||||||||
| LastUpdateDate: | 03/31/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 0101236730 | VA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 010100615 | 05 | VA | MEDICAID |