Healthcare Provider Details

I. General information

NPI: 1114021482
Provider Name (Legal Business Name): ELIZABETH MARGERY PELLETIER PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELIZABETH M BENSON

II. Dates (important events)

Enumeration Date: 09/08/2006
Last Update Date: 12/11/2024
Certification Date: 12/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1140 E MICHIGAN AVE STE 300
LANSING MI
48912-1806
US

IV. Provider business mailing address

6321 S CHANDLER RD
SAINT JOHNS MI
48879-9170
US

V. Phone/Fax

Practice location:
  • Phone: 517-364-5655
  • Fax: 517-364-5654
Mailing address:
  • Phone: 517-896-2946
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601006896
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA04209
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: