Provider Demographics
NPI:1518565399
Name:KOLSTAD, GINA (APRN)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:KOLSTAD
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:PO BOX 269
Mailing Address - Street 2:
Mailing Address - City:EAST GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06025-0269
Mailing Address - Country:US
Mailing Address - Phone:860-638-7299
Mailing Address - Fax:
Practice Address - Street 1:279 QUARRY RD # 2
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-3406
Practice Address - Country:US
Practice Address - Phone:860-638-7299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-13
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT9250363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health