Provider Demographics
NPI:1083090112
Name:MEHUS-WALLER, ELIZABETH (NP-C)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:MEHUS-WALLER
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:MRS
Other - First Name:ELIZABETH
Other - Middle Name:ANNE
Other - Last Name:MEHUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:301 NP AVE N
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-4835
Mailing Address - Country:US
Mailing Address - Phone:701-271-3344
Mailing Address - Fax:
Practice Address - Street 1:301 NP AVE N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-4835
Practice Address - Country:US
Practice Address - Phone:701-271-3344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-30
Last Update Date:2015-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR32597364SF0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health