Provider Demographics
NPI:1366141707
Name:PROSE, ELISABETH A (CBD)
Entity type:Individual
Prefix:
First Name:ELISABETH
Middle Name:A
Last Name:PROSE
Suffix:
Gender:F
Credentials:CBD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:WILLIMANTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06226-1341
Mailing Address - Country:US
Mailing Address - Phone:860-933-3854
Mailing Address - Fax:
Practice Address - Street 1:255 HIGH ST
Practice Address - Street 2:
Practice Address - City:WILLIMANTIC
Practice Address - State:CT
Practice Address - Zip Code:06226-1341
Practice Address - Country:US
Practice Address - Phone:860-933-3854
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-24
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT14882374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula