=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740077742
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELAINA BREE MALIS FNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/22/2025
-----------------------------------------------------
Last Update Date | 10/13/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 329 MAINE ST STE A200
-----------------------------------------------------
City | BRUNSWICK
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04011-3310
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-373-4700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 329 MAINE ST STE A200
-----------------------------------------------------
City | BRUNSWICK
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04011-3310
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-373-4700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | RN70640
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | CNP251374
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------