Basic Information
| Provider Information | |||||||||
| NPI: | 1699057836 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STROMBERG | ||||||||
| FirstName: | KARA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ELLIS | ||||||||
| OtherFirstName: | KARA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 85 LAFAYETTE STREET | ||||||||
| Address2: | |||||||||
| City: | NEW BRITAIN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060512016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602243642 | ||||||||
| FaxNumber: | 8602242760 | ||||||||
| Practice Location | |||||||||
| Address1: | 85 LAFAYETTE STREET | ||||||||
| Address2: | |||||||||
| City: | NEW BRITAIN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060512016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602243642 | ||||||||
| FaxNumber: | 8602242760 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2011 | ||||||||
| LastUpdateDate: | 12/22/2016 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 001055 | CT | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 004236346 | 05 | CT | MEDICAID |