Provider Demographics
NPI:1720620065
Name:BRAY, ALISA B (APRN)
Entity Type:Individual
Prefix:
First Name:ALISA
Middle Name:B
Last Name:BRAY
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 1:257 BACK RD
Mailing Address - Street 2:
Mailing Address - City:WINDHAM
Mailing Address - State:CT
Mailing Address - Zip Code:06280-1207
Mailing Address - Country:US
Mailing Address - Phone:860-933-0254
Mailing Address - Fax:860-933-0254
Practice Address - Street 1:112 MANSFIELD AVE
Practice Address - Street 2:
Practice Address - City:WILLIMANTIC
Practice Address - State:CT
Practice Address - Zip Code:06226-2045
Practice Address - Country:US
Practice Address - Phone:860-456-9116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-08
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CT8551363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program