Provider Demographics
NPI:1992826143
Name:FUKUSHIMA, ELIZABETH (LIC AC)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:FUKUSHIMA
Suffix:
Gender:F
Credentials:LIC AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:LIFEGATE HEALING ARTS
Mailing Address - Street 2:257 S. CHAMPLAIN STREET
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401
Mailing Address - Country:US
Mailing Address - Phone:802-651-9388
Mailing Address - Fax:
Practice Address - Street 1:LIFEGATE HEALING ARTS
Practice Address - Street 2:257 S. CHAMPLAIN STREET
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401
Practice Address - Country:US
Practice Address - Phone:802-651-9388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA263171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist