Provider Demographics
NPI:1114993987
Name:STURROCK, KELLEY LYN (MD)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:LYN
Last Name:STURROCK
Suffix:
Gender:F
Credentials:MD
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:STE. 201
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06106-2528
Mailing Address - Country:US
Mailing Address - Phone:860-246-8568
Mailing Address - Fax:860-728-5076
Practice Address - Street 1:100 RETREAT AVE
Practice Address - Street 2:STE 201
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-2528
Practice Address - Country:US
Practice Address - Phone:860-246-8568
Practice Address - Fax:860-728-5076
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2011-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101236730207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010100615Medicaid
I13313Medicare UPIN
005176V21Medicare ID - Type Unspecified