Provider Demographics
NPI:1629153903
Name:WILLETTE, ELIZABETH JORDAN (NP)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:JORDAN
Last Name:WILLETTE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MRS
Other - First Name:ELIZABETH
Other - Middle Name:JORDAN
Other - Last Name:WOODLIFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:2075 GLENN MITCHELL DR
Mailing Address - Street 2:STE 400
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23456-0179
Mailing Address - Country:US
Mailing Address - Phone:757-252-9365
Mailing Address - Fax:757-962-7217
Practice Address - Street 1:844 KEMPSVILLE RD
Practice Address - Street 2:SUITE 204
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-3927
Practice Address - Country:US
Practice Address - Phone:757-261-0700
Practice Address - Fax:757-962-1254
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024167146363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAQ76103Medicare UPIN
VA012306C00Medicare PIN