Healthcare Provider Details

I. General information

NPI: 1538397419
Provider Name (Legal Business Name): ELIZABETH FAGUE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2009
Last Update Date: 06/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 WATERFORD PARKWAY N.
WATERFORD CT
06385
US

IV. Provider business mailing address

51 HI TOP HILL RD
VOLUNTOWN CT
06384-1813
US

V. Phone/Fax

Practice location:
  • Phone: 860-437-3748
  • Fax:
Mailing address:
  • Phone: 860-376-8934
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number001497
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: