Basic Information
| Provider Information | |||||||||
| NPI: | 1538460407 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KUNKEL | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 FOUNDERS PLZ | ||||||||
| Address2: | STE 1802 | ||||||||
| City: | EAST HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061088301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8605695900 | ||||||||
| FaxNumber: | 8603102127 | ||||||||
| Practice Location | |||||||||
| Address1: | 763 BURNSIDE AVE | ||||||||
| Address2: | UNIT 5 | ||||||||
| City: | EAST HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061082791 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602919787 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2010 | ||||||||
| LastUpdateDate: | 01/25/2018 | ||||||||
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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 | 363LP0200X | 003553 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 004236346 | 05 | CT | MEDICAID |