Provider Demographics
NPI:1912595141
Name:PETERSEN, CAILIN
Entity Type:Individual
Prefix:
First Name:CAILIN
Middle Name:
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 N 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:TAFTVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06380-1407
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3 N 2ND AVE
Practice Address - Street 2:
Practice Address - City:TAFTVILLE
Practice Address - State:CT
Practice Address - Zip Code:06380-1407
Practice Address - Country:US
Practice Address - Phone:860-225-5543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-04
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTTCI0008769183500000X
CT0015573183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist