Provider Demographics
NPI:1457837122
Name:LIS, MICHAELA MORSE (AGACNP)
Entity Type:Individual
Prefix:MRS
First Name:MICHAELA
Middle Name:MORSE
Last Name:LIS
Suffix:
Gender:F
Credentials:AGACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:264 WESTMONT ST
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06117-2907
Mailing Address - Country:US
Mailing Address - Phone:860-841-3618
Mailing Address - Fax:
Practice Address - Street 1:80 SEYMOUR ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06102-8000
Practice Address - Country:US
Practice Address - Phone:860-841-3618
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-16
Last Update Date:2018-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2018013331363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care