Provider Demographics
NPI:1962400150
Name:HAUT, LISA
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:HAUT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:227 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TORRINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06790-5202
Mailing Address - Country:US
Mailing Address - Phone:860-618-5455
Mailing Address - Fax:860-618-2530
Practice Address - Street 1:227 MAIN ST
Practice Address - Street 2:
Practice Address - City:TORRINGTON
Practice Address - State:CT
Practice Address - Zip Code:06790-5202
Practice Address - Country:US
Practice Address - Phone:860-618-5455
Practice Address - Fax:860-618-2530
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001512363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT0015123630OtherCONNECTICARE
CT90350OtherGHI
CT787904OtherMVP
CTS79573Medicare UPIN
CT500001280Medicare PIN
CTP00328401Medicare PIN