Provider Demographics
NPI:1376335216
Name:WARDELL, ELISE KENI (PA-C)
Entity type:Individual
Prefix:
First Name:ELISE
Middle Name:KENI
Last Name:WARDELL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 WAKE ROBIN LN
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:CT
Mailing Address - Zip Code:06484-2005
Mailing Address - Country:US
Mailing Address - Phone:203-394-7582
Mailing Address - Fax:
Practice Address - Street 1:1678 ASYLUM AVE
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06117-2764
Practice Address - Country:US
Practice Address - Phone:860-232-4571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-19
Last Update Date:2025-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1234380363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant