Provider Demographics
NPI:1205236452
Name:PERREAULT, LISA
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:PERREAULT
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 1:34 JOHNSON RD
Mailing Address - Street 2:
Mailing Address - City:TOLLAND
Mailing Address - State:CT
Mailing Address - Zip Code:06084-2122
Mailing Address - Country:US
Mailing Address - Phone:800-995-2673
Mailing Address - Fax:888-979-6551
Practice Address - Street 1:34 JOHNSON RD
Practice Address - Street 2:
Practice Address - City:TOLLAND
Practice Address - State:CT
Practice Address - Zip Code:06084-2122
Practice Address - Country:US
Practice Address - Phone:800-995-2673
Practice Address - Fax:888-979-6551
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-25
Last Update Date:2014-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT84311163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse