Provider Demographics
NPI:1932830585
Name:TETREAULT, LAURYN ELIZABETH (PA)
Entity Type:Individual
Prefix:
First Name:LAURYN
Middle Name:ELIZABETH
Last Name:TETREAULT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:88 WEBER FARM RD
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360-5234
Mailing Address - Country:US
Mailing Address - Phone:401-932-8987
Mailing Address - Fax:
Practice Address - Street 1:20 YORK ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-3220
Practice Address - Country:US
Practice Address - Phone:203-688-4242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-23
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT6021363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical