Healthcare Provider Details

I. General information

NPI: 1255633673
Provider Name (Legal Business Name): LISA M SAGNELLA APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2010
Last Update Date: 11/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 CEDAR ST TMP 3
NEW HAVEN CT
06510-3206
US

IV. Provider business mailing address

275 MIRROR LN
GUILFORD CT
06437-1940
US

V. Phone/Fax

Practice location:
  • Phone: 203-785-2802
  • Fax: 203-785-6664
Mailing address:
  • Phone: 203-458-2396
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number004552
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: