Provider Demographics
NPI:1568947299
Name:BOMBARD, ELISE M
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:M
Last Name:BOMBARD
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 1:300 CENTRAL PARK APT 311
Mailing Address - Street 2:
Mailing Address - City:HOLDEN
Mailing Address - State:MA
Mailing Address - Zip Code:01520-1180
Mailing Address - Country:US
Mailing Address - Phone:508-335-6277
Mailing Address - Fax:
Practice Address - Street 1:548 PARK AVE
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01603-2537
Practice Address - Country:US
Practice Address - Phone:774-823-1500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-28
Last Update Date:2018-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN228478163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health