Provider Demographics
NPI:1457346538
Name:ELECK, LISA (APRN)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:ELECK
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 1:361 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06040-4127
Mailing Address - Country:US
Mailing Address - Phone:860-646-9929
Mailing Address - Fax:860-646-7999
Practice Address - Street 1:361 MAIN ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040-4127
Practice Address - Country:US
Practice Address - Phone:860-646-9929
Practice Address - Fax:860-646-7999
Is Sole Proprietor?:No
Enumeration Date:2005-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002904363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q09413Medicare UPIN
500001206Medicare ID - Type Unspecified