Provider Demographics
NPI:1083411904
Name:FERNSTROM, ELISE MAE
Entity type:Individual
Prefix:
First Name:ELISE
Middle Name:MAE
Last Name:FERNSTROM
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 BROOKLYN RD
Mailing Address - Street 2:
Mailing Address - City:POMFRET CENTER
Mailing Address - State:CT
Mailing Address - Zip Code:06259-2404
Mailing Address - Country:US
Mailing Address - Phone:860-250-6210
Mailing Address - Fax:
Practice Address - Street 1:401 W THAMES ST BLDG 301
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360-7155
Practice Address - Country:US
Practice Address - Phone:860-859-4563
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-27
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT14409363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health