Healthcare Provider Details

I. General information

NPI: 1750036646
Provider Name (Legal Business Name): LISA MARIE COVELLO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2022
Last Update Date: 02/18/2022
Certification Date: 02/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 BUXTON FARM RD STE 220
STAMFORD CT
06905-1230
US

IV. Provider business mailing address

14 APPLEBEE RD APT 1
STAMFORD CT
06905-3513
US

V. Phone/Fax

Practice location:
  • Phone: 203-658-6051
  • Fax: 888-397-2148
Mailing address:
  • Phone: 203-921-9709
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: