Provider Demographics
NPI:1538460407
Name:KUNKEL, TRACY L (APRN)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:L
Last Name:KUNKEL
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 1:111 FOUNDERS PLZ
Mailing Address - Street 2:STE 1802
Mailing Address - City:EAST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06108-8301
Mailing Address - Country:US
Mailing Address - Phone:860-569-5900
Mailing Address - Fax:860-310-2127
Practice Address - Street 1:763 BURNSIDE AVE
Practice Address - Street 2:UNIT 5
Practice Address - City:EAST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06108-2791
Practice Address - Country:US
Practice Address - Phone:860-291-9787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-09
Last Update Date:2018-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003553363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004236346Medicaid