Healthcare Provider Details

I. General information

NPI: 1922871599
Provider Name (Legal Business Name): BONNIE J ELLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2023
Last Update Date: 11/13/2023
Certification Date: 11/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

689 HOGAN RD
BANGOR ME
04401-3605
US

IV. Provider business mailing address

36 SILVER ST
WATERVILLE ME
04901-6514
US

V. Phone/Fax

Practice location:
  • Phone: 207-873-1131
  • Fax: 207-872-6014
Mailing address:
  • Phone: 207-877-5068
  • Fax: 207-872-6014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code222Z00000X
TaxonomyOrthotist
License Number
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: