Provider Demographics
NPI:1114435807
Name:DECELLES, ELISABETH RUTH (PMHNP)
Entity Type:Individual
Prefix:
First Name:ELISABETH
Middle Name:RUTH
Last Name:DECELLES
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2550 E SHOW LOW LAKE RD BLDG B
Mailing Address - Street 2:
Mailing Address - City:SHOW LOW
Mailing Address - State:AZ
Mailing Address - Zip Code:85901-7929
Mailing Address - Country:US
Mailing Address - Phone:928-537-2951
Mailing Address - Fax:928-537-2071
Practice Address - Street 1:1233 EDGEWATER ST NW
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97304-4049
Practice Address - Country:US
Practice Address - Phone:503-378-7526
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-16
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP10900363LP0808X
OR201902988NP-PP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health