Provider Demographics
NPI:1073974762
Name:KISSINGER, GAYLE
Entity Type:Individual
Prefix:
First Name:GAYLE
Middle Name:
Last Name:KISSINGER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 CLARA DR
Mailing Address - Street 2:
Mailing Address - City:MYSTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06355-1957
Mailing Address - Country:US
Mailing Address - Phone:860-536-4606
Mailing Address - Fax:860-536-9629
Practice Address - Street 1:10 CLARA DR
Practice Address - Street 2:
Practice Address - City:MYSTIC
Practice Address - State:CT
Practice Address - Zip Code:06355-1957
Practice Address - Country:US
Practice Address - Phone:860-536-4606
Practice Address - Fax:860-536-9629
Is Sole Proprietor?:No
Enumeration Date:2016-03-09
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0008599183500000X
RIRPH03856183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist