Provider Demographics
NPI:1780914374
Name:BEAL, KEMMARIE C (APRN)
Entity type:Individual
Prefix:
First Name:KEMMARIE
Middle Name:C
Last Name:BEAL
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 BROAD ST STE 103
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06095-3030
Mailing Address - Country:US
Mailing Address - Phone:860-776-0187
Mailing Address - Fax:815-205-4087
Practice Address - Street 1:340 BROAD ST STE 304
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06095-3030
Practice Address - Country:US
Practice Address - Phone:860-776-0187
Practice Address - Fax:815-205-4087
Is Sole Proprietor?:No
Enumeration Date:2010-01-05
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004289363LP0808X, 363L00000X
CT4289363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004289OtherLICENSE