Provider Demographics
NPI:1023819794
Name:EUBANKS, ELISE AUDREY
Entity type:Individual
Prefix:
First Name:ELISE
Middle Name:AUDREY
Last Name:EUBANKS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:94 MISSION HILLS DR SW
Mailing Address - Street 2:
Mailing Address - City:CARTERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30120-7443
Mailing Address - Country:US
Mailing Address - Phone:770-655-2832
Mailing Address - Fax:
Practice Address - Street 1:300 CHEROKEE PL
Practice Address - Street 2:
Practice Address - City:CARTERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30121-2964
Practice Address - Country:US
Practice Address - Phone:770-606-2366
Practice Address - Fax:770-606-2372
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-20
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHTC001747156F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156F00000XEye and Vision Services ProvidersTechnician/Technologist