Provider Demographics
NPI:1831758366
Name:RUIZ, KELLY (PA)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:RUIZ
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 1:7 KENT LN
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06002-1326
Mailing Address - Country:US
Mailing Address - Phone:860-713-9655
Mailing Address - Fax:
Practice Address - Street 1:21 GRAND ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-1541
Practice Address - Country:US
Practice Address - Phone:860-550-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-09
Last Update Date:2019-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1163512363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant