Healthcare Provider Details

I. General information

NPI: 1437519600
Provider Name (Legal Business Name): ELISE MCLAWHORN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2016
Last Update Date: 03/03/2020
Certification Date: 03/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6760 MAIN ST
GLOUCESTER VA
23061-5143
US

IV. Provider business mailing address

PO BOX 857
GLOUCESTER VA
23061-0857
US

V. Phone/Fax

Practice location:
  • Phone: 804-693-3500
  • Fax: 804-693-3503
Mailing address:
  • Phone: 804-693-3500
  • Fax: 804-693-3503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024173344
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: