Provider Demographics
NPI:1598797862
Name:KIRWIN, KATHLEEN MARY (APRN)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARY
Last Name:KIRWIN
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 1:116 S MAIN ST
Mailing Address - Street 2:THE CARRIAGE HOUSE
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-4217
Mailing Address - Country:US
Mailing Address - Phone:203-697-0807
Mailing Address - Fax:203-265-3651
Practice Address - Street 1:116 S MAIN ST
Practice Address - Street 2:THE CARRIAGE HOUSE
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492-4217
Practice Address - Country:US
Practice Address - Phone:203-697-0807
Practice Address - Fax:203-265-3651
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2011-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002756363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT3248477OtherAETNA
CT5600002756CT2OtherANTHEM