Basic Information
| Provider Information | |||||||||
| NPI: | 1679519375 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARRELL | ||||||||
| FirstName: | CISALEE | ||||||||
| MiddleName: | GENE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | APRN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HARRELL | ||||||||
| OtherFirstName: | CISALEE | ||||||||
| OtherMiddleName: | GENE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | APRN | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 62 W EGGLESTON ST | ||||||||
| Address2: | |||||||||
| City: | BLOOMFIELD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060023249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606676255 | ||||||||
| FaxNumber: | 8606676875 | ||||||||
| Practice Location | |||||||||
| Address1: | 555 WILLARD AVE | ||||||||
| Address2: | |||||||||
| City: | NEWINGTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061112631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606676255 | ||||||||
| FaxNumber: | 8606676875 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 000191 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 000191 | 01 | CT | APRN | OTHER |