Provider Demographics
NPI:1124171103
Name:KOWALCZUK, LINDA S (APRN)
Entity type:Individual
Prefix:MRS
First Name:LINDA
Middle Name:S
Last Name:KOWALCZUK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:MRS
Other - First Name:LINDA
Other - Middle Name:S
Other - Last Name:KOWALCZUK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:40 HYDE ST
Mailing Address - Street 2:
Mailing Address - City:TORRINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06790-6006
Mailing Address - Country:US
Mailing Address - Phone:860-496-0790
Mailing Address - Fax:
Practice Address - Street 1:720 HOPMEADOW ST
Practice Address - Street 2:
Practice Address - City:SIMSBURY
Practice Address - State:CT
Practice Address - Zip Code:06070-2224
Practice Address - Country:US
Practice Address - Phone:860-651-3519
Practice Address - Fax:860-651-4133
Is Sole Proprietor?:No
Enumeration Date:2007-01-21
Last Update Date:2014-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001329363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTS35875Medicare UPIN