Basic Information
| Provider Information | |||||||||
| NPI: | 1326136979 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOELLE | ||||||||
| FirstName: | KENNETH | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 32928 | ||||||||
| Address2: | ANESTHESIA ASSOC OF NEW LONDON | ||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061502928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8007201664 | ||||||||
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| Practice Location | |||||||||
| Address1: | 365 MONTAUK AVE | ||||||||
| Address2: | ANESTHESIA DEPT. | ||||||||
| City: | NEW LONDON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 063204700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8604420711 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2006 | ||||||||
| LastUpdateDate: | 02/01/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 000199 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.