MEDICARE: LISA PERREAULT

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	163W00000X	Registered Nurse	84311	CT

General Provider Information

NPI Number	:	1205236452
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA PERREAULT

Provider Business Mailing Address
First Line	:	34 JOHNSON RD
Second Line	:
City	:	TOLLAND
State	:	CT
Zip	:	06084-2122
Country	:	US
Telephone Number	:	800-995-2673
Fax Number	:	888-979-6551

Provider Business Practice Location Address
First Line	:	34 JOHNSON RD
Second Line	:
City	:	TOLLAND
State	:	CT
Zip	:	06084-2122
Country	:	US
Telephone Number	:	800-995-2673
Fax Number	:	888-979-6551

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

Provider Enumeration Date	:	08/25/2014
Last Update Date	:	08/25/2014

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