Provider Demographics
NPI:1700285673
Name:DO, LISAN (APRN)
Entity Type:Individual
Prefix:
First Name:LISAN
Middle Name:
Last Name:DO
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 1:20 BELROSE AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTHINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06489-3602
Mailing Address - Country:US
Mailing Address - Phone:203-788-5280
Mailing Address - Fax:
Practice Address - Street 1:20 BELROSE AVE
Practice Address - Street 2:
Practice Address - City:SOUTHINGTON
Practice Address - State:CT
Practice Address - Zip Code:06489-3602
Practice Address - Country:US
Practice Address - Phone:203-788-5280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-17
Last Update Date:2014-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5845363LA2200X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology