Provider Demographics
NPI:1104114545
Name:POTTASCH, LISA ANNE (APRN)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:ANNE
Last Name:POTTASCH
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4BERKSHIRE BOULEVARD
Mailing Address - Street 2:ABILITY BEYOND DISABILITY
Mailing Address - City:BETHEL
Mailing Address - State:CT
Mailing Address - Zip Code:06801
Mailing Address - Country:US
Mailing Address - Phone:203-775-4700
Mailing Address - Fax:203-775-8028
Practice Address - Street 1:4BERKSHIRE BOULEVARD
Practice Address - Street 2:ABILITY BEYOND DISABILITY
Practice Address - City:BETHEL
Practice Address - State:CT
Practice Address - Zip Code:06801
Practice Address - Country:US
Practice Address - Phone:203-775-4700
Practice Address - Fax:203-775-8028
Is Sole Proprietor?:No
Enumeration Date:2011-07-19
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT004652364SA2200X
NYF305500-1364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health