Provider Demographics
NPI:1700380706
Name:KIRKLAND, JOEL DONNEL SR
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:DONNEL
Last Name:KIRKLAND
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 BREWSTER ST
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-1804
Mailing Address - Country:US
Mailing Address - Phone:203-800-6144
Mailing Address - Fax:
Practice Address - Street 1:30 BREWSTER ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-1804
Practice Address - Country:US
Practice Address - Phone:203-800-6144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-22
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTHCA.0001408372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes372600000XNursing Service Related ProvidersAdult CompanionGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTHCA.0001408Medicaid
CT43095686-000OtherCONSUMER PROTECTION