Provider Demographics
NPI:1669669727
Name:ROUSSEAU, KELLY (PA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:ROUSSEAU
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:BIAFORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:114 WOODLAND ST
Mailing Address - Street 2:DEPARTMENT OF SURGERY
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06105-1208
Mailing Address - Country:US
Mailing Address - Phone:860-714-4694
Mailing Address - Fax:860-714-8096
Practice Address - Street 1:114 WOODLAND ST
Practice Address - Street 2:DEPARTMENT OF SURGERY
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06105-1208
Practice Address - Country:US
Practice Address - Phone:860-714-4694
Practice Address - Fax:860-714-8096
Is Sole Proprietor?:No
Enumeration Date:2007-10-02
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical