Healthcare Provider Details

I. General information

NPI: 1407776032
Provider Name (Legal Business Name): ELISA MICHELLE WALSH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2026
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12310 WOODCREEK DR STE E
WILLIS TX
77318-7022
US

IV. Provider business mailing address

537 BROOK TERRANCE LN
WILLIS TX
77378-6703
US

V. Phone/Fax

Practice location:
  • Phone: 936-243-3047
  • Fax:
Mailing address:
  • Phone: 303-374-4667
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1034605
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: