Healthcare Provider Details

I. General information

NPI: 1659941615
Provider Name (Legal Business Name): ELISSA IRENE TREMBLAY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2021
Last Update Date: 10/23/2022
Certification Date: 03/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 NORTHPORT AVE FL 1
BELFAST ME
04915-6069
US

IV. Provider business mailing address

119 NORTHPORT AVE FL 1
BELFAST ME
04915-6069
US

V. Phone/Fax

Practice location:
  • Phone: 207-505-4567
  • Fax:
Mailing address:
  • Phone: 207-505-4567
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP211111
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: