Provider Demographics
NPI:1699320937
Name:KOLACZENKO, AMY (APRN)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:KOLACZENKO
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 1:7 MINNIE LN
Mailing Address - Street 2:
Mailing Address - City:WETHERSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06109-3997
Mailing Address - Country:US
Mailing Address - Phone:860-463-6412
Mailing Address - Fax:
Practice Address - Street 1:631 S QUAKER LN
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06110-1026
Practice Address - Country:US
Practice Address - Phone:860-233-5133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-05
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT8368363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner