Healthcare Provider Details

I. General information

NPI: 1003868092
Provider Name (Legal Business Name): LISA ANN CLOUTIER APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 11/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 MAIN ST STE 22D
WINDSOR LOCKS CT
06096-1904
US

IV. Provider business mailing address

4 BROWNSTONE RD
EAST GRANBY CT
06026-9705
US

V. Phone/Fax

Practice location:
  • Phone: 860-463-9535
  • Fax: 860-831-1033
Mailing address:
  • Phone: 860-651-9159
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Clinical Nurse Specialist
License Number001734
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License Number001734
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License Number001734
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: