Provider Demographics
NPI:1376767442
Name:AZINHEIRA, LISA (LO)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:AZINHEIRA
Suffix:
Gender:F
Credentials:LO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:86 DEPAUW CIR
Mailing Address - Street 2:
Mailing Address - City:EAST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06108-1315
Mailing Address - Country:US
Mailing Address - Phone:860-289-8180
Mailing Address - Fax:
Practice Address - Street 1:112 S WHITNEY ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06105-4123
Practice Address - Country:US
Practice Address - Phone:860-523-0339
Practice Address - Fax:860-523-0310
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001476156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician