Provider Demographics
NPI:1669483533
Name:BASTIAANSE, KAYLEEN (APRN)
Entity Type:Individual
Prefix:MS
First Name:KAYLEEN
Middle Name:
Last Name:BASTIAANSE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4 FARM SPRINGS RD
Mailing Address - Street 2:PROHEALTH PHYSICIANS
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06032-2573
Mailing Address - Country:US
Mailing Address - Phone:860-284-5200
Mailing Address - Fax:860-284-5333
Practice Address - Street 1:538 LITCHFIELD ST
Practice Address - Street 2:SUITE 103
Practice Address - City:TORRINGTON
Practice Address - State:CT
Practice Address - Zip Code:06790-6669
Practice Address - Country:US
Practice Address - Phone:860-489-5148
Practice Address - Fax:860-489-4752
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT001974363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTS82081Medicare UPIN