=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710926696
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LOIS-ANN CERISE LOVELACE RPA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/06/2006
-----------------------------------------------------
Last Update Date | 04/15/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 385 W MAIN ST
-----------------------------------------------------
City | AVON
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06001-4357
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-777-1280
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1290 SILAS DEANE HWY HARTFORD HEALTHCARE-CVO
-----------------------------------------------------
City | WETHERSFIELD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06109-4337
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 011248
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 5034
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------