Provider Demographics
NPI:1962919605
Name:ERNST-SIXTO, KATHARINA (LICENSED OPTICIAN)
Entity type:Individual
Prefix:MRS
First Name:KATHARINA
Middle Name:
Last Name:ERNST-SIXTO
Suffix:
Gender:F
Credentials:LICENSED OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:495 HAWLEY LN
Mailing Address - Street 2:
Mailing Address - City:STRATFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06614-1514
Mailing Address - Country:US
Mailing Address - Phone:203-375-5819
Mailing Address - Fax:203-377-4337
Practice Address - Street 1:495 HAWLEY LN
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:CT
Practice Address - Zip Code:06614-1514
Practice Address - Country:US
Practice Address - Phone:203-375-5819
Practice Address - Fax:203-377-4337
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-03
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001623156FX1800X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1114438652Medicaid