Healthcare Provider Details

I. General information

NPI: 1245195866
Provider Name (Legal Business Name): ELISHA BOLTON APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELISHA GOWEN

II. Dates (important events)

Enumeration Date: 12/16/2025
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 JOHN PAUL JONES CIR STE 275
PORTSMOUTH VA
23708-2197
US

IV. Provider business mailing address

620 JOHN PAUL JONES CIR STE 275
PORTSMOUTH VA
23708-2197
US

V. Phone/Fax

Practice location:
  • Phone: 757-953-3382
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License Number209031570
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: