Provider Demographics
NPI:1568673192
Name:PROVENCHER, ELYSE (LAC, MAC)
Entity type:Individual
Prefix:
First Name:ELYSE
Middle Name:
Last Name:PROVENCHER
Suffix:
Gender:F
Credentials:LAC, MAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68 HARBOUR HEIGHTS DR
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-2141
Mailing Address - Country:US
Mailing Address - Phone:410-573-1938
Mailing Address - Fax:
Practice Address - Street 1:2009 TIDEWATER COLONY WAY
Practice Address - Street 2:SUITE B2
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-2127
Practice Address - Country:US
Practice Address - Phone:410-573-1938
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU01477171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist