Provider Demographics
NPI:1093343741
Name:SPALLA, ELISE KATHERINE (RN)
Entity Type:Individual
Prefix:MRS
First Name:ELISE
Middle Name:KATHERINE
Last Name:SPALLA
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:ELISE
Other - Middle Name:
Other - Last Name:GOLEMBESKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:175 SCOTT SWAMP RD
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06032-3124
Mailing Address - Country:US
Mailing Address - Phone:860-751-6265
Mailing Address - Fax:
Practice Address - Street 1:175 SCOTT SWAMP RD
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032-3124
Practice Address - Country:US
Practice Address - Phone:860-751-6265
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-30
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT88959163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1811520810Medicaid