Provider Demographics
NPI:1649498254
Name:CAPOBIANCO, LISA ANN (APRN)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:ANN
Last Name:CAPOBIANCO
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 1:50 COMMERCE PARK
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06460-3565
Mailing Address - Country:US
Mailing Address - Phone:203-882-2066
Mailing Address - Fax:203-882-2074
Practice Address - Street 1:50 COMMERCE PARK
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06460-3565
Practice Address - Country:US
Practice Address - Phone:203-882-2066
Practice Address - Fax:203-882-2074
Is Sole Proprietor?:No
Enumeration Date:2007-04-22
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001279363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008017638Medicaid
CT1407975675OtherGROUP NPI