Provider Demographics
NPI:1174951636
Name:PROVENCHER, ELIANE (NHP-BC)
Entity type:Individual
Prefix:
First Name:ELIANE
Middle Name:
Last Name:PROVENCHER
Suffix:
Gender:F
Credentials:NHP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 ROCKWELL RD
Mailing Address - Street 2:
Mailing Address - City:STAFFORD SPRINGS
Mailing Address - State:CT
Mailing Address - Zip Code:06076-4513
Mailing Address - Country:US
Mailing Address - Phone:860-888-8613
Mailing Address - Fax:
Practice Address - Street 1:345 N MAIN ST
Practice Address - Street 2:NEIHA
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06117-2515
Practice Address - Country:US
Practice Address - Phone:860-547-1489
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-21
Last Update Date:2013-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVRND20007152133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education