Provider Demographics
NPI:1083845226
Name:GIANNELLI, KYLA
Entity Type:Individual
Prefix:
First Name:KYLA
Middle Name:
Last Name:GIANNELLI
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 1:100 RETREAT AVE
Mailing Address - Street 2:SUITE 811
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06106-2528
Mailing Address - Country:US
Mailing Address - Phone:860-522-5712
Mailing Address - Fax:860-520-4270
Practice Address - Street 1:100 RETREAT AVE
Practice Address - Street 2:SUITE 811
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-2528
Practice Address - Country:US
Practice Address - Phone:860-522-5712
Practice Address - Fax:860-520-4270
Is Sole Proprietor?:No
Enumeration Date:2009-08-05
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA3807363A00000X
CT2390363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant