Provider Demographics
NPI:1073596482
Name:TALBOT, ELISA ANN (LPN)
Entity Type:Individual
Prefix:
First Name:ELISA
Middle Name:ANN
Last Name:TALBOT
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:ELISA
Other - Middle Name:ANN
Other - Last Name:LIVERSEED
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:W12345 HWY 16-60
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:WI
Mailing Address - Zip Code:53925-8901
Mailing Address - Country:US
Mailing Address - Phone:920-623-4938
Mailing Address - Fax:
Practice Address - Street 1:W12345 HWY 16-60
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:WI
Practice Address - Zip Code:53925-8901
Practice Address - Country:US
Practice Address - Phone:920-623-4938
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI26133-031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39946800Medicaid