Basic Information
| Provider Information | |||||||||
| NPI: | 1518221142 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MITCHELL | ||||||||
| FirstName: | CAITLYN | ||||||||
| MiddleName: | KENNEDY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KENNEDY | ||||||||
| OtherFirstName: | CAITLYN | ||||||||
| OtherMiddleName: | ASHLEY | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | OD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 69 BUCK HILL RD | ||||||||
| Address2: | |||||||||
| City: | RIDGEFIELD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 068772702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8452161195 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 87 GRANDVIEW AVE | ||||||||
| Address2: | |||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067082514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035742020 | ||||||||
| FaxNumber: | 2034651481 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2012 | ||||||||
| LastUpdateDate: | 07/20/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152WC0802X | TUV007835-1 | NY | N | Eye and Vision Services Providers | Optometrist | Corneal and Contact Management | 152W00000X | 3251 | CT | Y | Eye and Vision Services Providers | Optometrist | 152W00000X | TUV007835 | NY | N | Eye and Vision Services Providers | Optometrist |
No ID Information.