Basic Information
| Provider Information | |||||||||
| NPI: | 1770012601 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILLARD | ||||||||
| FirstName: | ALYSSA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1290 SILAS DEANE HWY | ||||||||
| Address2: | |||||||||
| City: | WETHERSFIELD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061094337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8609726977 | ||||||||
| FaxNumber: | 8609727040 | ||||||||
| Practice Location | |||||||||
| Address1: | 385 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | AVON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060014357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606962150 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2017 | ||||||||
| LastUpdateDate: | 06/05/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.