Provider Demographics
NPI:1376150235
Name:ELJ, LARRY VERNON (RN)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:VERNON
Last Name:ELJ
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 1ST ST NW
Mailing Address - Street 2:
Mailing Address - City:CHISHOLM
Mailing Address - State:MN
Mailing Address - Zip Code:55719-1704
Mailing Address - Country:US
Mailing Address - Phone:218-969-9968
Mailing Address - Fax:
Practice Address - Street 1:516 SOUTH POKEGAMA AVE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-3800
Practice Address - Country:US
Practice Address - Phone:218-327-2001
Practice Address - Fax:218-327-0456
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-25
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
273R00000X
MN7856363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No273R00000XHospital UnitsPsychiatric Unit