Healthcare Provider Details

I. General information

NPI: 1306417563
Provider Name (Legal Business Name): ELIZABETH ANNE CROSS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2021
Last Update Date: 08/25/2021
Certification Date: 08/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

760 W FRANKLIN ST
JACKSON MI
49201-2048
US

IV. Provider business mailing address

714 OBRIEN RD
JACKSON MI
49201-8982
US

V. Phone/Fax

Practice location:
  • Phone: 517-205-2700
  • Fax:
Mailing address:
  • Phone: 517-416-4158
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberL-302211
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number4704323389
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704323389
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: