Healthcare Provider Details

I. General information

NPI: 1740077742
Provider Name (Legal Business Name): ELAINA BREE MALIS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2025
Last Update Date: 10/13/2025
Certification Date: 10/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

329 MAINE ST STE A200
BRUNSWICK ME
04011-3310
US

IV. Provider business mailing address

329 MAINE ST STE A200
BRUNSWICK ME
04011-3310
US

V. Phone/Fax

Practice location:
  • Phone: 207-373-4700
  • Fax:
Mailing address:
  • Phone: 207-373-4700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN70640
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP251374
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: