Provider Demographics
NPI:1497542468
Name:FIASCONARO, LISA D
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:D
Last Name:FIASCONARO
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 1:4 DAISY LN
Mailing Address - Street 2:
Mailing Address - City:ELLINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06029-3240
Mailing Address - Country:US
Mailing Address - Phone:860-416-9986
Mailing Address - Fax:
Practice Address - Street 1:1715 ELLINGTON RD
Practice Address - Street 2:
Practice Address - City:SOUTH WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06074-2707
Practice Address - Country:US
Practice Address - Phone:860-644-4408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-23
Last Update Date:2025-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001835225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant