Provider Demographics
NPI:1760556310
Name:ARCHULETA, ELAINE E (NP)
Entity Type:Individual
Prefix:
First Name:ELAINE
Middle Name:E
Last Name:ARCHULETA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:ELAINE
Other - Middle Name:
Other - Last Name:ARCHULETA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 741729
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-1729
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5405 S 500 E STE 204
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-7420
Practice Address - Country:US
Practice Address - Phone:801-479-0184
Practice Address - Fax:801-479-5642
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT222610-4405363L00000X
UT2226104405363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner