Provider Demographics
NPI:1114083466
Name:ERMMARINO, ELISSA (DO)
Entity type:Individual
Prefix:DR
First Name:ELISSA
Middle Name:
Last Name:ERMMARINO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:ELISSA
Other - Middle Name:
Other - Last Name:SCHLICHTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 896206
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28289-6206
Mailing Address - Country:US
Mailing Address - Phone:252-244-1785
Mailing Address - Fax:252-244-2876
Practice Address - Street 1:620 FARM LIFE AVE
Practice Address - Street 2:
Practice Address - City:VANCEBORO
Practice Address - State:NC
Practice Address - Zip Code:28586-7673
Practice Address - Country:US
Practice Address - Phone:252-244-1785
Practice Address - Fax:252-244-2876
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2017-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A7368207Q00000X
NY212592207Q00000X
NC2013-01436207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2013-01436OtherNORTH CAROLINA MEDICAL BOARD
CA20A7368OtherCALIFORNIA MEDICAL LICENSE
NY212592OtherNEW YORK MEDICAL LICENSE
NY212592OtherNEW YORK MEDICAL LICENSE