Provider Demographics
NPI:1306196472
Name:BIVINS, ELISA BROOKE
Entity Type:Individual
Prefix:
First Name:ELISA
Middle Name:BROOKE
Last Name:BIVINS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELISA
Other - Middle Name:BROOKE
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:25892 N JAMES MADISON HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:NEW CANTON
Mailing Address - State:VA
Mailing Address - Zip Code:23123-0220
Mailing Address - Country:US
Mailing Address - Phone:434-581-3271
Mailing Address - Fax:434-581-1105
Practice Address - Street 1:102 BROADDUS AVENUE
Practice Address - Street 2:SUITE 200
Practice Address - City:BOWLING GREEN
Practice Address - State:VA
Practice Address - Zip Code:22427-9404
Practice Address - Country:US
Practice Address - Phone:804-632-1030
Practice Address - Fax:804-632-1033
Is Sole Proprietor?:No
Enumeration Date:2012-09-14
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024170177363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner