Provider Demographics
NPI:1558636019
Name:GASTON, ELISE MADJO (LPN)
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:MADJO
Last Name:GASTON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12903 PINECREST RD
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20171-2601
Mailing Address - Country:US
Mailing Address - Phone:703-597-2988
Mailing Address - Fax:
Practice Address - Street 1:12903 PINECREST RD
Practice Address - Street 2:
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20171-2601
Practice Address - Country:US
Practice Address - Phone:703-597-2988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-16
Last Update Date:2012-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0002085420164W00000X
VA1401140286376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No376K00000XNursing Service Related ProvidersNurse's Aide