MEDICARE: ELIZABETH A MAYERSON APRN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	000781	CT
2	363LF0000X	Family Nurse Practitioner	000781	CT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1053367060	OTHER		NPI

General Provider Information

NPI Number	:	1053367060
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIZABETH A MAYERSON APRN

Provider Business Mailing Address
First Line	:	1776 BOSTON TPKE
Second Line	:
City	:	COVENTRY
State	:	CT
Zip	:	06238-1160
Country	:	US
Telephone Number	:	860-742-0807
Fax Number	:	860-742-8702

Provider Business Practice Location Address
First Line	:	1776 BOSTON TPKE
Second Line	:
City	:	COVENTRY
State	:	CT
Zip	:	06238-1160
Country	:	US
Telephone Number	:	860-742-0807
Fax Number	:	860-742-8702

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/25/2006
Last Update Date	:	08/31/2011

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Directions to “ ELIZABETH A MAYERSON APRN” Practice Location

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