Provider Demographics
NPI:1316036940
Name:RAUSCH, KERYN J (APRN)
Entity Type:Individual
Prefix:
First Name:KERYN
Middle Name:J
Last Name:RAUSCH
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 KENSINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:NEW BRITAIN
Mailing Address - State:CT
Mailing Address - Zip Code:06051-3916
Mailing Address - Country:US
Mailing Address - Phone:860-224-6231
Mailing Address - Fax:860-224-6260
Practice Address - Street 1:1 LAKE ST
Practice Address - Street 2:BLDG. B
Practice Address - City:NEW BRITAIN
Practice Address - State:CT
Practice Address - Zip Code:06052-1396
Practice Address - Country:US
Practice Address - Phone:860-826-4453
Practice Address - Fax:860-826-6219
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000988363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT080988OtherCONNECTICARE ID
CT378146OtherWELLCARE MEDICARE
CT40APRN988CT01OtherBCFP MEDICAID
CT2V6209OtherHEALTH NET ID
CT40APRN988CT01OtherBCBS ID
CT1255448155OtherGHMC NPI
CTC01373Medicare ID - Type UnspecifiedGHMC GROUP MEDICARE ID
CTP90239Medicare UPIN