Healthcare Provider Details

I. General information

NPI: 1740956044
Provider Name (Legal Business Name): ELISE MARIE STAVISH DNP, CRNP, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2021
Last Update Date: 05/05/2025
Certification Date: 05/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

959 WYOMING AVE
SCRANTON PA
18509-3023
US

IV. Provider business mailing address

959 WYOMING AVE
SCRANTON PA
18509-3023
US

V. Phone/Fax

Practice location:
  • Phone: 570-344-9684
  • Fax: 570-504-0612
Mailing address:
  • Phone: 570-954-6968
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP024223
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: