Basic Information
| Provider Information | |||||||||
| NPI: | 1801366646 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NAGLE | ||||||||
| FirstName: | KERIN | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | APRN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GILLIGAN | ||||||||
| OtherFirstName: | KERIN | ||||||||
| OtherMiddleName: | ELIZABETH | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 500 ALBANY AVE | ||||||||
| Address2: | |||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8604626764 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | COMMUNITY HEALTH SERVICES | ||||||||
| Address2: | 500 ALBANY AVE | ||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061202508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602499625 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2018 | ||||||||
| LastUpdateDate: | 09/08/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | F09181069 | CT | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 007963 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.