Provider Demographics
NPI:1740760701
Name:DUTTON, ELYSA (APRN)
Entity Type:Individual
Prefix:
First Name:ELYSA
Middle Name:
Last Name:DUTTON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:ELYSA
Other - Middle Name:
Other - Last Name:NESSENZIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:PO BOX 751649
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1649
Mailing Address - Country:US
Mailing Address - Phone:843-789-1620
Mailing Address - Fax:843-724-2440
Practice Address - Street 1:5133 RIVERS AVE
Practice Address - Street 2:
Practice Address - City:N CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-6338
Practice Address - Country:US
Practice Address - Phone:843-789-1786
Practice Address - Fax:843-958-1263
Is Sole Proprietor?:No
Enumeration Date:2018-08-20
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC22073363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP5379Medicaid