Healthcare Provider Details

I. General information

NPI: 1457346538
Provider Name (Legal Business Name): LISA ELECK APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

361 MAIN ST
MANCHESTER CT
06040-4127
US

IV. Provider business mailing address

361 MAIN ST
MANCHESTER CT
06040-4127
US

V. Phone/Fax

Practice location:
  • Phone: 860-646-9929
  • Fax: 860-646-7999
Mailing address:
  • Phone: 860-646-9929
  • Fax: 860-646-7999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number002904
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: