Provider Demographics
NPI:1104073220
Name:KACZANOWSKI, KRISTEN ANN (DC)
Entity type:Individual
Prefix:DR
First Name:KRISTEN
Middle Name:ANN
Last Name:KACZANOWSKI
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 MAIN STREET
Mailing Address - Street 2:SUITE #412
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06604-4406
Mailing Address - Country:US
Mailing Address - Phone:203-335-7260
Mailing Address - Fax:203-335-2561
Practice Address - Street 1:1115 MAIN STREET
Practice Address - Street 2:SUITE #412
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06604-4406
Practice Address - Country:US
Practice Address - Phone:203-335-7260
Practice Address - Fax:203-335-2561
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-20
Last Update Date:2008-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1076CT111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT050001076CT03OtherBC/BS