Provider Demographics
NPI:1124214895
Name:THELAN, ELIZABETH Z (CPNP)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:Z
Last Name:THELAN
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ELIZABETH
Other - Last Name:THELAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:APRN-BC
Mailing Address - Street 1:2051 CHARLIE HALL BLVD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29414
Mailing Address - Country:US
Mailing Address - Phone:843-573-2535
Mailing Address - Fax:843-573-2534
Practice Address - Street 1:374 HUDLOW RD
Practice Address - Street 2:
Practice Address - City:FOREST CITY
Practice Address - State:NC
Practice Address - Zip Code:28043-9444
Practice Address - Country:US
Practice Address - Phone:828-245-0095
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-17
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3357363LP0200X
NC5018499363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5018499OtherLICENSURE