Healthcare Provider Details

I. General information

NPI: 1164067443
Provider Name (Legal Business Name): MESSAN LAWSON APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/11/2019
Last Update Date: 09/16/2020
Certification Date: 09/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

149 FLORENCE ST
MANCHESTER CT
06040-5407
US

IV. Provider business mailing address

149 FLORENCE ST
MANCHESTER CT
06040-5407
US

V. Phone/Fax

Practice location:
  • Phone: 857-891-2409
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2020038282
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number139890
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: