Healthcare Provider Details

I. General information

NPI: 1568947299
Provider Name (Legal Business Name): ELISE M BOMBARD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2018
Last Update Date: 09/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

548 PARK AVE
WORCESTER MA
01603-2537
US

IV. Provider business mailing address

300 CENTRAL PARK APT 311
HOLDEN MA
01520-1180
US

V. Phone/Fax

Practice location:
  • Phone: 774-823-1500
  • Fax:
Mailing address:
  • Phone: 508-335-6277
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License NumberRN228478
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: