Healthcare Provider Details

I. General information

NPI: 1437678554
Provider Name (Legal Business Name): ELIZABETH KAY ELSEA WILMORE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2017
Last Update Date: 04/29/2020
Certification Date: 04/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 N WILLOW AVE
COOKEVILLE TN
38501-2368
US

IV. Provider business mailing address

150 N WILLOW AVE
COOKEVILLE TN
38501-2368
US

V. Phone/Fax

Practice location:
  • Phone: 931-528-1485
  • Fax:
Mailing address:
  • Phone: 931-528-1485
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3424
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: