Provider Demographics
NPI:1932287893
Name:KINNELL-RUST, HOLLY ROXANNE (FNP)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:ROXANNE
Last Name:KINNELL-RUST
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 POMFRET ST
Mailing Address - Street 2:
Mailing Address - City:PUTNAM
Mailing Address - State:CT
Mailing Address - Zip Code:06260-1836
Mailing Address - Country:US
Mailing Address - Phone:860-963-6371
Mailing Address - Fax:860-963-6413
Practice Address - Street 1:320 POMFRET ST
Practice Address - Street 2:
Practice Address - City:PUTNAM
Practice Address - State:CT
Practice Address - Zip Code:06260-1836
Practice Address - Country:US
Practice Address - Phone:860-963-6371
Practice Address - Fax:860-963-6413
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA191964363L00000X
MO2010026851363LF0000X
CT7023363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1932287893Medicaid
P00859525OtherRAILROAD MEDICARE
CT008073029Medicaid
AR184085758Medicaid
431560263OtherTRICARE WEST