Provider Demographics
NPI:1053367060
Name:MAYERSON, ELIZABETH A (APRN)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:A
Last Name:MAYERSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:CLINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1776 BOSTON TPKE
Mailing Address - Street 2:
Mailing Address - City:COVENTRY
Mailing Address - State:CT
Mailing Address - Zip Code:06238-1160
Mailing Address - Country:US
Mailing Address - Phone:860-742-0807
Mailing Address - Fax:860-742-8702
Practice Address - Street 1:1776 BOSTON TPKE
Practice Address - Street 2:
Practice Address - City:COVENTRY
Practice Address - State:CT
Practice Address - Zip Code:06238-1160
Practice Address - Country:US
Practice Address - Phone:860-742-0807
Practice Address - Fax:860-742-8702
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2011-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000781363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
1053367060OtherNPI
1053367060OtherNPI