Provider Demographics
NPI:1700858529
Name:KELLERMAN, KATHLEEN (PA)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:KELLERMAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:282 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06106-3322
Mailing Address - Country:US
Mailing Address - Phone:860-545-8549
Mailing Address - Fax:860-545-8569
Practice Address - Street 1:282 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-3322
Practice Address - Country:US
Practice Address - Phone:860-545-8549
Practice Address - Fax:860-545-8569
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001414363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTQ04763Medicare UPIN