Provider Demographics
NPI:1497944425
Name:STEPHENSON, KERRY ROSE (APRN)
Entity Type:Individual
Prefix:MS
First Name:KERRY
Middle Name:ROSE
Last Name:STEPHENSON
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 1:1 SHAWS CV
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-4902
Mailing Address - Country:US
Mailing Address - Phone:860-447-8304
Mailing Address - Fax:860-443-8720
Practice Address - Street 1:575 MAIN ST FL 2
Practice Address - Street 2:ATTN: CREDENTIALING DPT
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-2845
Practice Address - Country:US
Practice Address - Phone:860-347-6971
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-16
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003654363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004236338Medicaid