Healthcare Provider Details

I. General information

NPI: 1063142982
Provider Name (Legal Business Name): LINDSAY M DIFELICE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2022
Last Update Date: 08/30/2022
Certification Date: 08/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 SEYMOUR ST
HARTFORD CT
06102-8000
US

IV. Provider business mailing address

80 SEYMOUR ST
HARTFORD CT
06102-8000
US

V. Phone/Fax

Practice location:
  • Phone: 860-972-5022
  • Fax:
Mailing address:
  • Phone: 860-972-5022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number005754
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number23
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: