Healthcare Provider Details

I. General information

NPI: 1548875776
Provider Name (Legal Business Name): LISA WRUBEL APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2020
Last Update Date: 04/19/2023
Certification Date: 04/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 VAUXHALL ST
NEW LONDON CT
06320-5711
US

IV. Provider business mailing address

8 NATHAN HALE DR
EAST LYME CT
06333-1458
US

V. Phone/Fax

Practice location:
  • Phone: 860-705-4969
  • Fax:
Mailing address:
  • Phone: 860-705-4969
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number11641
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number82201
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: