Healthcare Provider Details

I. General information

NPI: 1114083466
Provider Name (Legal Business Name): ELISSA ERMMARINO D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELISSA SCHLICHTER D.O.

II. Dates (important events)

Enumeration Date: 12/29/2006
Last Update Date: 03/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 FARM LIFE AVE
VANCEBORO NC
28586-7673
US

IV. Provider business mailing address

PO BOX 896206
CHARLOTTE NC
28289-6206
US

V. Phone/Fax

Practice location:
  • Phone: 252-244-1785
  • Fax: 252-244-2876
Mailing address:
  • Phone: 252-244-1785
  • Fax: 252-244-2876

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A7368
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number212592
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2013-01436
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: