Provider Demographics
NPI:1407109465
Name:MAES, ELISSA
Entity Type:Individual
Prefix:
First Name:ELISSA
Middle Name:
Last Name:MAES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5203 MAIN ST LOT 137
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:48450-9275
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:217 E SANILAC RD
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:MI
Practice Address - Zip Code:48471-1383
Practice Address - Country:US
Practice Address - Phone:810-648-0330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-16
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other