Provider Demographics
NPI:1730483082
Name:STEPHENS, ELISA (NP)
Entity Type:Individual
Prefix:
First Name:ELISA
Middle Name:
Last Name:STEPHENS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1868
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-1868
Mailing Address - Country:US
Mailing Address - Phone:307-733-2046
Mailing Address - Fax:307-733-6289
Practice Address - Street 1:640 E BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8642
Practice Address - Country:US
Practice Address - Phone:307-733-2046
Practice Address - Fax:307-733-6289
Is Sole Proprietor?:No
Enumeration Date:2010-12-30
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN165748163WP0808X
AZAP3882164W00000X
WY38889.1584364SP0808X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No164W00000XNursing Service ProvidersLicensed Practical Nurse
No364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health