Provider Demographics
NPI:1780028571
Name:FARDELMANN, KRISTEN LEIGH (MD)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:LEIGH
Last Name:FARDELMANN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 208051
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06520-8051
Mailing Address - Country:US
Mailing Address - Phone:203-785-2802
Mailing Address - Fax:203-785-6664
Practice Address - Street 1:333 CEDAR STREET, TMP 3
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06520
Practice Address - Country:US
Practice Address - Phone:203-785-2802
Practice Address - Fax:203-785-6664
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-23
Last Update Date:2018-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CT61365207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program