1104114545 NPI number — MRS. LISA ANNE POTTASCH APRN

Table of content: MRS. LISA ANNE POTTASCH APRN (NPI 1104114545)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104114545 NPI number — MRS. LISA ANNE POTTASCH APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POTTASCH
Provider First Name:
LISA
Provider Middle Name:
ANNE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
APRN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104114545
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/17/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4BERKSHIRE BOULEVARD
Provider Second Line Business Mailing Address:
ABILITY BEYOND DISABILITY
Provider Business Mailing Address City Name:
BETHEL
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06801
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-775-4700
Provider Business Mailing Address Fax Number:
203-775-8028

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4BERKSHIRE BOULEVARD
Provider Second Line Business Practice Location Address:
ABILITY BEYOND DISABILITY
Provider Business Practice Location Address City Name:
BETHEL
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-775-4700
Provider Business Practice Location Address Fax Number:
203-775-8028
Provider Enumeration Date:
07/19/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 364SA2200X , with the licence number:  004652 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 364SA2200X , with the licence number: F305500-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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