Provider Demographics
NPI:1962505453
Name:REILLY, ELISABETH A (APRN)
Entity Type:Individual
Prefix:MS
First Name:ELISABETH
Middle Name:A
Last Name:REILLY
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 1:374 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06513-3733
Mailing Address - Country:US
Mailing Address - Phone:203-777-7411
Mailing Address - Fax:
Practice Address - Street 1:374 GRAND AVE
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06513-3733
Practice Address - Country:US
Practice Address - Phone:203-777-7411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTE46044163WP0200X
CT000590363LP0222X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0222XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics, Critical Care
No163WP0200XNursing Service ProvidersRegistered NursePediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
400000590CT01OtherBCBS MAP
OV9806OtherPHS
061470493OtherFIRST CHOICE
061470493OtherUNITED PAYORS
400000590CT01OtherBC HEALTH PLAN
400000590CT01OtherBCBS NATL
061470493OtherCT HEALTH PIONEER
400000590CT01OtherBCBS FED PPO
061470493OtherCHAMPUS TRICARE
061470493OtherCOMMUNITY
400000590CT01OtherBCBS CENT 90
CT004184694Medicaid
061470493OtherPHCS
061470493OtherONE HEALTH PLANHEALTH CAR
061470493OtherNE DIRECT
095000OtherCONNECTICARE
400000590CT01OtherBCBS PREFERRED
400000590CT01OtherBCBS NATL
CT004184694Medicaid