Healthcare Provider Details

I. General information

NPI: 1356760011
Provider Name (Legal Business Name): CHARISSA SALLIE ELLIOTT FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2014
Last Update Date: 05/23/2024
Certification Date: 05/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1706 W AGENCY RD
WEST BURLINGTON IA
52655-1667
US

IV. Provider business mailing address

1706 W AGENCY RD
WEST BURLINGTON IA
52655-1667
US

V. Phone/Fax

Practice location:
  • Phone: 319-768-5858
  • Fax: 319-752-4653
Mailing address:
  • Phone: 319-768-5858
  • Fax: 319-752-4653

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA087662
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN144548
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code163WP0000X
TaxonomyPain Management Registered Nurse
License NumberRN144548
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: