Healthcare Provider Details

I. General information

NPI: 1639944531
Provider Name (Legal Business Name): ELAINE M DUNNIVAN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2023
Last Update Date: 12/13/2023
Certification Date: 12/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6701 PETERS CREEK RD
ROANOKE VA
24019-4060
US

IV. Provider business mailing address

6701 PETERS CREEK RD
ROANOKE VA
24019-4060
US

V. Phone/Fax

Practice location:
  • Phone: 800-765-7130
  • Fax:
Mailing address:
  • Phone: 800-765-7130
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024188915
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: