Healthcare Provider Details

I. General information

NPI: 1578003554
Provider Name (Legal Business Name): ELYSE BUTTERY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELYSE EDWARDS

II. Dates (important events)

Enumeration Date: 02/24/2017
Last Update Date: 05/11/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 WIMBLEDON SQ # 1
CHESAPEAKE VA
23320-4946
US

IV. Provider business mailing address

856 J CLYDE MORRIS BLVD STE A
NEWPORT NEWS VA
23601-1318
US

V. Phone/Fax

Practice location:
  • Phone: 757-436-2995
  • Fax:
Mailing address:
  • Phone: 757-316-5800
  • Fax: 757-534-5190

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024174567
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number0024174567
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: