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General NPI Number Information
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NPI Number | 1356607428
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Entity Type | Organization
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Legal Business Name | ELYSE PROVENCHER LLC
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Dates
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Enumeration Date | 04/03/2012
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Last Update Date | 04/03/2012
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Provider Practice Location Address
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Address Line | 2009 TIDEWATER COLONY DR SUITE B2
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City | ANNAPOLIS
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State | MD
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Zip | 21401-2107
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Country | US
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Telephone | 410-573-1938
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Fax |
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Provider Business Mailing Address
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Address Line | 2009 TIDEWATER COLONY DR SUITE B2
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City | ANNAPOLIS
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State | MD
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Zip | 21401-2107
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Country | US
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Telephone | 410-573-1938
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | ELYSE PROVENCHER
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Credential | L.AC.
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Telephone | 410-573-1938
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171100000X
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Taxonomy Name | Acupuncturist
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License Number |
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License Number State |
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