Healthcare Provider Details

I. General information

NPI: 1033590120
Provider Name (Legal Business Name): ELIZABETH WILLETTS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2015
Last Update Date: 03/16/2026
Certification Date: 03/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 SALEM TPKE STE 102
NORWICH CT
06360-6533
US

IV. Provider business mailing address

1290 SILAS DEANE HWY HHC-CVO
WETHERSFIELD CT
06109-4337
US

V. Phone/Fax

Practice location:
  • Phone: 860-889-0147
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberCT7102
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: