Healthcare Provider Details

I. General information

NPI: 1881004828
Provider Name (Legal Business Name): ELIZABETH CHASSE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2014
Last Update Date: 11/07/2022
Certification Date: 11/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 WOLCOTT ST
BRISTOL CT
06010-9701
US

IV. Provider business mailing address

160 WOLCOTT ST
BRISTOL CT
06010-9701
US

V. Phone/Fax

Practice location:
  • Phone: 860-589-8872
  • Fax: 860-589-6468
Mailing address:
  • Phone: 860-589-8872
  • Fax: 860-589-6468

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD15861
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number066325
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: