Provider Demographics
NPI:1790882025
Name:DINSMORE, ELISSA BETH (NP)
Entity Type:Individual
Prefix:
First Name:ELISSA
Middle Name:BETH
Last Name:DINSMORE
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 1:1 PRESTIGE PL STE 550
Mailing Address - Street 2:
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-6115
Mailing Address - Country:US
Mailing Address - Phone:937-762-1310
Mailing Address - Fax:937-522-8068
Practice Address - Street 1:1045 CHANNINGWAY DR STE A
Practice Address - Street 2:
Practice Address - City:FAIRBORN
Practice Address - State:OH
Practice Address - Zip Code:45324-9252
Practice Address - Country:US
Practice Address - Phone:937-878-8644
Practice Address - Fax:937-878-8646
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024166938363L00000X
OHCOA.11091-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010335779Medicaid
VA012360C61Medicare PIN