Provider Demographics
NPI:1871852723
Name:PELLETIER, ELAINE MARIE (BA)
Entity type:Individual
Prefix:MRS
First Name:ELAINE
Middle Name:MARIE
Last Name:PELLETIER
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1485 S SEMORAN BLVD
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32792-5533
Mailing Address - Country:US
Mailing Address - Phone:321-397-3000
Mailing Address - Fax:407-681-5477
Practice Address - Street 1:1485 S SEMORAN BLVD
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-5533
Practice Address - Country:US
Practice Address - Phone:321-397-3000
Practice Address - Fax:407-681-5477
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-14
Last Update Date:2012-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLP436213496070171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator