Healthcare Provider Details

I. General information

NPI: 1548360720
Provider Name (Legal Business Name): ELISABETH UPSHAW MCRAE CPNP, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 11/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 E JEFFERSON ST
CHARLOTTESVILLE VA
22902-5354
US

IV. Provider business mailing address

1011 E JEFFERSON ST
CHARLOTTESVILLE VA
22902-5354
US

V. Phone/Fax

Practice location:
  • Phone: 434-296-9161
  • Fax: 434-296-1036
Mailing address:
  • Phone: 434-296-9161
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number0001063672
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number0024063672
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: