Provider Demographics
NPI:1417926957
Name:GAGNON, LISA MARIE (APRN)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:GAGNON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 BOSTON POST RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:CT
Mailing Address - Zip Code:06443-2225
Mailing Address - Country:US
Mailing Address - Phone:203-245-0496
Mailing Address - Fax:203-245-8697
Practice Address - Street 1:230 BOSTON POST RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:CT
Practice Address - Zip Code:06443-2225
Practice Address - Country:US
Practice Address - Phone:203-245-0496
Practice Address - Fax:203-245-8697
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2013-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002510363LP0200X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics