Healthcare Provider Details

I. General information

NPI: 1790937670
Provider Name (Legal Business Name): LISSY DAVIS POULOSE APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2008
Last Update Date: 01/21/2022
Certification Date: 01/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

324 ELM ST STE 202B
MONROE CT
06468-2284
US

IV. Provider business mailing address

324 ELM ST STE 202B
MONROE CT
06468-2284
US

V. Phone/Fax

Practice location:
  • Phone: 203-880-5335
  • Fax: 203-907-1234
Mailing address:
  • Phone: 203-880-5335
  • Fax: 203-907-1234

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number003902
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: