Provider Demographics
NPI:1689151110
Name:VICIOSO, LISSELOT
Entity Type:Individual
Prefix:
First Name:LISSELOT
Middle Name:
Last Name:VICIOSO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 SOUTH ST FL 2
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06110-1967
Mailing Address - Country:US
Mailing Address - Phone:860-890-3032
Mailing Address - Fax:
Practice Address - Street 1:104 DOUGLAS ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06114-2421
Practice Address - Country:US
Practice Address - Phone:860-890-3032
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-27
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program