Provider Demographics
NPI:1679172357
Name:ELEZOVIC, MEJRA
Entity Type:Individual
Prefix:
First Name:MEJRA
Middle Name:
Last Name:ELEZOVIC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:731 27TH ST N
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-3130
Mailing Address - Country:US
Mailing Address - Phone:701-306-1277
Mailing Address - Fax:
Practice Address - Street 1:1670 E GATEWAY CIR S APT 214
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-3767
Practice Address - Country:US
Practice Address - Phone:701-318-4524
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-22
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1451608376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker