Provider Demographics
NPI:1154661783
Name:CARLSON, KELLY MARIE (RPHT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:CARLSON
Suffix:
Gender:F
Credentials:RPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:227 STONEYCREST DRIVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457
Mailing Address - Country:US
Mailing Address - Phone:860-729-1904
Mailing Address - Fax:
Practice Address - Street 1:30 COLD SPRINGS ROAD
Practice Address - Street 2:
Practice Address - City:ROCKYHILL
Practice Address - State:CT
Practice Address - Zip Code:06067
Practice Address - Country:US
Practice Address - Phone:860-257-5872
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-19
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0003067183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician