Provider Demographics
NPI:1386621266
Name:DOHERTY-FISHER, ELYSA MARIA (APRN)
Entity type:Individual
Prefix:MS
First Name:ELYSA
Middle Name:MARIA
Last Name:DOHERTY-FISHER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:ELYSA
Other - Middle Name:MARIA
Other - Last Name:DOHERTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:22 THOMASSIAN DR
Mailing Address - Street 2:
Mailing Address - City:MARLBOROUGH
Mailing Address - State:CT
Mailing Address - Zip Code:06447-1398
Mailing Address - Country:US
Mailing Address - Phone:860-508-7789
Mailing Address - Fax:
Practice Address - Street 1:22 THOMASSIAN DR
Practice Address - Street 2:
Practice Address - City:MARLBOROUGH
Practice Address - State:CT
Practice Address - Zip Code:06447-1398
Practice Address - Country:US
Practice Address - Phone:860-508-7789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-30
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT02377363LP0808X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTP12940Medicare UPIN