Provider Demographics
NPI:1639427735
Name:LINDO, MARVELLE LISANDRA (APRN)
Entity Type:Individual
Prefix:MISS
First Name:MARVELLE
Middle Name:LISANDRA
Last Name:LINDO
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 1:106 EASTVIEW DR
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06095-1815
Mailing Address - Country:US
Mailing Address - Phone:860-995-1053
Mailing Address - Fax:
Practice Address - Street 1:26 SHENIPSIT LAKE RD
Practice Address - Street 2:
Practice Address - City:TOLLAND
Practice Address - State:CT
Practice Address - Zip Code:06084-2332
Practice Address - Country:US
Practice Address - Phone:860-872-2999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-21
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT005088363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1639427735Medicaid