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General NPI Number Information
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NPI Number | 1700870201
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Entity Type | Individual
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Provider Name | ELISSA J CHARBONNEAU DO
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Gender | Female
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Dates
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Enumeration Date | 09/12/2005
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Last Update Date | 02/18/2011
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Provider Practice Location Address
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Address Line | 24 HAWTHORNE CIRCLE
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City | YARMOUTH
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State | ME
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Zip | 04096-8337
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Country | US
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Telephone | 207-851-1724
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Fax |
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Provider Business Mailing Address
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Address Line | 301 US ROUTE ONE BUILDING C
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City | SCARBOROUGH
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State | ME
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Zip | 04074-9701
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Country | US
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Telephone | 207-396-8600
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Fax | 207-396-8632
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208100000X
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Taxonomy Name | Physical Medicine & Rehabilitation Physician
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License Number | 1399
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License Number State | ME
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