Provider Demographics
NPI:1639694441
Name:CERRETA-DIAL, ELYSIA MARIE (AGNP)
Entity Type:Individual
Prefix:
First Name:ELYSIA
Middle Name:MARIE
Last Name:CERRETA-DIAL
Suffix:
Gender:F
Credentials:AGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2595 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:STRATFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06615-5855
Mailing Address - Country:US
Mailing Address - Phone:203-345-0404
Mailing Address - Fax:203-908-4110
Practice Address - Street 1:2595 MAIN ST
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:CT
Practice Address - Zip Code:06615-5855
Practice Address - Country:US
Practice Address - Phone:203-345-0404
Practice Address - Fax:203-908-4110
Is Sole Proprietor?:No
Enumeration Date:2017-08-14
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT7166363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health