Provider Demographics
NPI:1356854202
Name:ELKS, MACEY DIANA (NP)
Entity Type:Individual
Prefix:MRS
First Name:MACEY
Middle Name:DIANA
Last Name:ELKS
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 1:3051 WATSON BLVD STE 525
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31093-8556
Mailing Address - Country:US
Mailing Address - Phone:478-953-4563
Mailing Address - Fax:478-953-4564
Practice Address - Street 1:3051 WATSON BLVD STE 525
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31093
Practice Address - Country:US
Practice Address - Phone:478-953-4563
Practice Address - Fax:478-953-4564
Is Sole Proprietor?:No
Enumeration Date:2017-11-14
Last Update Date:2018-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN224167363L00000X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner