Provider Demographics
NPI:1578952206
Name:BACCHUS, ELIZABETH R (NP)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:R
Last Name:BACCHUS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:R
Other - Last Name:BACCHUS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNP
Mailing Address - Street 1:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:WETUMPKA
Mailing Address - State:AL
Mailing Address - Zip Code:36092-0003
Mailing Address - Country:US
Mailing Address - Phone:334-514-3821
Mailing Address - Fax:334-514-3686
Practice Address - Street 1:2256 GILMER AVE
Practice Address - Street 2:
Practice Address - City:TALLASSEE
Practice Address - State:AL
Practice Address - Zip Code:36078-7114
Practice Address - Country:US
Practice Address - Phone:334-567-8633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-19
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-114945363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily