Healthcare Provider Details

I. General information

NPI: 1639694441
Provider Name (Legal Business Name): ELYSIA MARIE CERRETA-DIAL AGNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2017
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2595 MAIN ST
STRATFORD CT
06615-5855
US

IV. Provider business mailing address

2595 MAIN ST
STRATFORD CT
06615-5855
US

V. Phone/Fax

Practice location:
  • Phone: 203-345-0404
  • Fax: 203-908-4110
Mailing address:
  • Phone: 203-345-0404
  • Fax: 203-908-4110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number7166
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number7166
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: