Provider Demographics
NPI:1811223738
Name:MOSS, ELAINA SUSAN (RN)
Entity Type:Individual
Prefix:MRS
First Name:ELAINA
Middle Name:SUSAN
Last Name:MOSS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:ELAINA
Other - Middle Name:SUSAN
Other - Last Name:FUSSY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4301 MANOR FIELD WAY APT 104
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-3776
Mailing Address - Country:US
Mailing Address - Phone:763-228-0783
Mailing Address - Fax:
Practice Address - Street 1:800 E 28TH ST
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-3723
Practice Address - Country:US
Practice Address - Phone:865-342-8900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1695582163W00000X
NC083446367500000X
MN764367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8053817Medicaid