Provider Demographics
NPI:1700340411
Name:HAYLETTE, ELIZABETH DARLENE (MS, PA-C)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:DARLENE
Last Name:HAYLETTE
Suffix:
Gender:F
Credentials:MS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 ALLEN ST
Mailing Address - Street 2:
Mailing Address - City:TERRYVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06786-6405
Mailing Address - Country:US
Mailing Address - Phone:860-371-8662
Mailing Address - Fax:
Practice Address - Street 1:245 ALVORD PARK RD STE A2
Practice Address - Street 2:
Practice Address - City:TORRINGTON
Practice Address - State:CT
Practice Address - Zip Code:06790-7217
Practice Address - Country:US
Practice Address - Phone:860-482-8539
Practice Address - Fax:860-482-0258
Is Sole Proprietor?:No
Enumeration Date:2019-01-27
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4390363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004197738Medicaid