Provider Demographics
NPI:1467448878
Name:BEAULIEU, KIMBERLY L (PA-C)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:L
Last Name:BEAULIEU
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:520 HARTFORD TPKE
Mailing Address - Street 2:STE M
Mailing Address - City:VERNON ROCKVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06066-5044
Mailing Address - Country:US
Mailing Address - Phone:860-871-8321
Mailing Address - Fax:860-875-6271
Practice Address - Street 1:675 TOWER AVE
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06112-1264
Practice Address - Country:US
Practice Address - Phone:860-714-2913
Practice Address - Fax:860-714-8988
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT000195363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT970000880Medicare PIN