Basic Information
| Provider Information | |||||||||
| NPI: | 1720620065 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRAY | ||||||||
| FirstName: | ALISA | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 257 BACK RD | ||||||||
| Address2: | |||||||||
| City: | WINDHAM | ||||||||
| State: | CT | ||||||||
| PostalCode: | 062801207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8609330254 | ||||||||
| FaxNumber: | 8609330254 | ||||||||
| Practice Location | |||||||||
| Address1: | 112 MANSFIELD AVE | ||||||||
| Address2: | |||||||||
| City: | WILLIMANTIC | ||||||||
| State: | CT | ||||||||
| PostalCode: | 062262045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8604569116 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/08/2019 | ||||||||
| LastUpdateDate: | 12/11/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/11/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 363LF0000X | 8551 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.