Provider Demographics
NPI:1790937670
Name:POULOSE, LISSY DAVIS (APRN)
Entity Type:Individual
Prefix:MRS
First Name:LISSY
Middle Name:DAVIS
Last Name:POULOSE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 ELM ST
Mailing Address - Street 2:STE 202B
Mailing Address - City:MONROE
Mailing Address - State:CT
Mailing Address - Zip Code:06468-2284
Mailing Address - Country:US
Mailing Address - Phone:203-880-5335
Mailing Address - Fax:203-907-1234
Practice Address - Street 1:324 ELM ST
Practice Address - Street 2:STE 202B
Practice Address - City:MONROE
Practice Address - State:CT
Practice Address - Zip Code:06468-2284
Practice Address - Country:US
Practice Address - Phone:203-880-5335
Practice Address - Fax:203-907-1234
Is Sole Proprietor?:No
Enumeration Date:2008-10-22
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003902363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health