Provider Demographics
NPI:1063898617
Name:FORD, KELLIE ANGELA (APRN)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:ANGELA
Last Name:FORD
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:35 TALCOTTVILLE RD
Mailing Address - Street 2:
Mailing Address - City:VERNON
Mailing Address - State:CT
Mailing Address - Zip Code:06066-5261
Mailing Address - Country:US
Mailing Address - Phone:860-870-6385
Mailing Address - Fax:
Practice Address - Street 1:35 TALCOTTVILLE ROAD
Practice Address - Street 2:SUITE 6
Practice Address - City:VERNON
Practice Address - State:CT
Practice Address - Zip Code:06066-5261
Practice Address - Country:US
Practice Address - Phone:860-870-6385
Practice Address - Fax:860-870-0625
Is Sole Proprietor?:No
Enumeration Date:2015-08-05
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT6161363L00000X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care