Provider Demographics
NPI:1124403837
Name:HERWIG, ELIZABETH (NP)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:HERWIG
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 EXCHANGE ST STE B7
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HILL
Mailing Address - State:GA
Mailing Address - Zip Code:31324-7646
Mailing Address - Country:US
Mailing Address - Phone:912-756-2273
Mailing Address - Fax:
Practice Address - Street 1:2201 POOLER PKWY STE 700
Practice Address - Street 2:
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322-4407
Practice Address - Country:US
Practice Address - Phone:912-800-6004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-23
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28195852A163W00000X
GARN310134363L00000X
IN71005788A363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201321730Medicaid
IN000000964513OtherANTHEM PROVIDER NUMBER
IN000000964513OtherANTHEM PROVIDER NUMBER