Healthcare Provider Details

I. General information

NPI: 1104114545
Provider Name (Legal Business Name): LISA ANNE POTTASCH APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2011
Last Update Date: 10/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4BERKSHIRE BOULEVARD ABILITY BEYOND DISABILITY
BETHEL CT
06801
US

IV. Provider business mailing address

4BERKSHIRE BOULEVARD ABILITY BEYOND DISABILITY
BETHEL CT
06801
US

V. Phone/Fax

Practice location:
  • Phone: 203-775-4700
  • Fax: 203-775-8028
Mailing address:
  • Phone: 203-775-4700
  • Fax: 203-775-8028

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License Number004652
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License NumberF305500-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: