Basic Information
| Provider Information | |||||||||
| NPI: | 1699786582 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LABONTE | ||||||||
| FirstName: | KRISTINA | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | P.A.-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GOSPIC | ||||||||
| OtherFirstName: | KRISTINA | ||||||||
| OtherMiddleName: | D | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | P.A.-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 67 MAPLE AVE | ||||||||
| Address2: | |||||||||
| City: | DERBY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064181328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037327325 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 135 DIVISION ST STE 2 | ||||||||
| Address2: | |||||||||
| City: | ANSONIA | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064012135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2033082705 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2006 | ||||||||
| LastUpdateDate: | 05/11/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 001520 | CT | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 1520 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.