Provider Demographics
NPI:1174592505
Name:ELMORE, ELIZABETH ALICE (RN)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ALICE
Last Name:ELMORE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4119 MENASHA AVE
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-1145
Mailing Address - Country:US
Mailing Address - Phone:920-684-4444
Mailing Address - Fax:
Practice Address - Street 1:10200 FRANCIS CREEK RD
Practice Address - Street 2:
Practice Address - City:TWO RIVERS
Practice Address - State:WI
Practice Address - Zip Code:54241-9128
Practice Address - Country:US
Practice Address - Phone:920-686-0752
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38246100Medicaid