Basic Information
Provider Information | |||||||||
NPI: | 1316940190 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KILCULLEN | ||||||||
FirstName: | PATRICIA | ||||||||
MiddleName: | STORK | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | APRN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4 STURDEVANT DR | ||||||||
Address2: |   | ||||||||
City: | DANBURY | ||||||||
State: | CT | ||||||||
PostalCode: | 068113543 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2037485754 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 19 BRADHURST AVE | ||||||||
Address2: |   | ||||||||
City: | HAWTHORNE | ||||||||
State: | NY | ||||||||
PostalCode: | 105322140 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9144937000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/24/2005 | ||||||||
LastUpdateDate: | 10/16/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 002016 | CT | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LA2200X | F302513-1 | NY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
ID | Type | State | Issuer | Description | 004247814 | 05 | CT |   | MEDICAID | 500001411 | 01 |   | UNSPECIFIED | OTHER |