Provider Demographics
NPI:1477140721
Name:GAGNON, KIMBERLY (LO)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:GAGNON
Suffix:
Gender:F
Credentials:LO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 BUCKLAND RD
Mailing Address - Street 2:
Mailing Address - City:WETHERSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06109-1204
Mailing Address - Country:US
Mailing Address - Phone:203-887-1932
Mailing Address - Fax:
Practice Address - Street 1:505 WILLARD AVE STE 2B
Practice Address - Street 2:
Practice Address - City:NEWINGTON
Practice Address - State:CT
Practice Address - Zip Code:06111-2650
Practice Address - Country:US
Practice Address - Phone:860-667-0207
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-21
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1694156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician