Provider Demographics
NPI:1366715179
Name:BERGERON, LISA MARIE (APRN)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:BERGERON
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 1:627 NORWICH SALEM TPKE UNIT 2
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:CT
Mailing Address - Zip Code:06370-1066
Mailing Address - Country:US
Mailing Address - Phone:860-222-0949
Mailing Address - Fax:203-503-3254
Practice Address - Street 1:627 NORWICH SALEM TPKE UNIT 2
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:CT
Practice Address - Zip Code:06370-1066
Practice Address - Country:US
Practice Address - Phone:860-222-0949
Practice Address - Fax:888-326-5828
Is Sole Proprietor?:No
Enumeration Date:2012-02-10
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4923363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004235900Medicaid