Provider Demographics
NPI:1164806592
Name:DEHAVEN, ELIZABETH A (FNP-BC)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:A
Last Name:DEHAVEN
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:A
Other - Last Name:DALTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-BC
Mailing Address - Street 1:101 KINGSBURY BLVD
Mailing Address - Street 2:
Mailing Address - City:FREDERICKTOWN
Mailing Address - State:MO
Mailing Address - Zip Code:63645-7959
Mailing Address - Country:US
Mailing Address - Phone:573-561-1555
Mailing Address - Fax:573-783-5951
Practice Address - Street 1:101 KINGSBURY BLVD
Practice Address - Street 2:
Practice Address - City:FREDERICKTOWN
Practice Address - State:MO
Practice Address - Zip Code:63645-7959
Practice Address - Country:US
Practice Address - Phone:573-561-1555
Practice Address - Fax:573-783-5951
Is Sole Proprietor?:No
Enumeration Date:2015-07-15
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015021530363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily