Provider Demographics
NPI:1962679969
Name:SPICER, LISA M (ANP-BC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:SPICER
Suffix:
Gender:F
Credentials:ANP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 CAMBRIDGE DR STE 201
Mailing Address - Street 2:
Mailing Address - City:TRUMBULL
Mailing Address - State:CT
Mailing Address - Zip Code:06611-4763
Mailing Address - Country:US
Mailing Address - Phone:203-335-0195
Mailing Address - Fax:203-335-7293
Practice Address - Street 1:900 MADISON AVE
Practice Address - Street 2:SUITE 209
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-5534
Practice Address - Country:US
Practice Address - Phone:203-335-0195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-09
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003792363LA2200X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT003792OtherCONNECTICUT APRN LICENSE
CT500001737Medicare PIN