Healthcare Provider Details

I. General information

NPI: 1255707139
Provider Name (Legal Business Name): MICHELE LYNN ELLETT CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MICHELE LYNN WATERS CPCP

II. Dates (important events)

Enumeration Date: 08/14/2015
Last Update Date: 03/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 E MARSHALL ST DEPT. OF NEUROSURGERY
RICHMOND VA
23298-5051
US

IV. Provider business mailing address

PO BOX 91734
RICHMOND VA
23291-1734
US

V. Phone/Fax

Practice location:
  • Phone: 804-828-9165
  • Fax: 804-828-4493
Mailing address:
  • Phone: 804-358-6100
  • Fax: 804-342-7619

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number0024172824
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: