Provider Demographics
NPI:1316940190
Name:KILCULLEN, PATRICIA STORK (APRN)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:STORK
Last Name:KILCULLEN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 STURDEVANT DR
Mailing Address - Street 2:
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06811-3543
Mailing Address - Country:US
Mailing Address - Phone:203-748-5754
Mailing Address - Fax:
Practice Address - Street 1:19 BRADHURST AVE
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:NY
Practice Address - Zip Code:10532-2140
Practice Address - Country:US
Practice Address - Phone:914-493-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2015-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002016363LA2200X
NYF302513-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004247814Medicaid
500001411OtherUNSPECIFIED
CT004247814Medicaid
CT500001411Medicare ID - Type Unspecified