Healthcare Provider Details

I. General information

NPI: 1497673784
Provider Name (Legal Business Name): ALYSSA RAFFAELA KONSPORE MAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2026
Last Update Date: 07/06/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 SUMMER LN
NORTH HAVEN CT
06473-3567
US

IV. Provider business mailing address

22 SUMMER LN
NORTH HAVEN CT
06473-3567
US

V. Phone/Fax

Practice location:
  • Phone: 203-654-0407
  • Fax:
Mailing address:
  • Phone: 203-654-0407
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number24100335
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: