Basic Information
| Provider Information | |||||||||
| NPI: | 1295354397 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KLYN | ||||||||
| FirstName: | MEAGAN | ||||||||
| MiddleName: | ASHLEY NORBERTA | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 267 GRANT STREET | ||||||||
| Address2: | BRIDGEPORT HOSPITAL | ||||||||
| City: | BRIDGEPORT | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2033843000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 267 GRANT STREET | ||||||||
| Address2: | BRIDGEPORT HOSPITAL | ||||||||
| City: | BRIDGEPORT | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2033843000 | ||||||||
| FaxNumber: | 2033844294 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2020 | ||||||||
| LastUpdateDate: | 02/03/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 01/10/2022 | ||||||||
| NPIReactivationDate: | 02/03/2022 | ||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 390200000X | CT | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.