MEDICARE: ELYSE PROVENCHER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171100000X	Acupuncturist

General Provider Information

NPI Number	:	1356607428
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELYSE PROVENCHER LLC

Provider Business Mailing Address
First Line	:	2009 TIDEWATER COLONY DR
Second Line	:	SUITE B2
City	:	ANNAPOLIS
State	:	MD
Zip	:	21401-2107
Country	:	US
Telephone Number	:	410-573-1938
Fax Number	:

Provider Business Practice Location Address
First Line	:	2009 TIDEWATER COLONY DR
Second Line	:	SUITE B2
City	:	ANNAPOLIS
State	:	MD
Zip	:	21401-2107
Country	:	US
Telephone Number	:	410-573-1938
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ELYSE PROVENCHER
Credential	:	L.AC.
Telephone Number	:	410-573-1938

Provider Enumeration Date	:	04/03/2012
Last Update Date	:	04/03/2012

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Directions to “ELYSE PROVENCHER LLC ” Practice Location

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