Provider Demographics
NPI:1851328439
Name:MIELOCH, ELIZABETH ANNE (MSN, APRN, BC)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANNE
Last Name:MIELOCH
Suffix:
Gender:F
Credentials:MSN, APRN, BC
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:ANN
Other - Last Name:WHITEMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSN, APRN, BC
Mailing Address - Street 1:26335 SHUMANS WAY
Mailing Address - Street 2:
Mailing Address - City:SOUTH LYON
Mailing Address - State:MI
Mailing Address - Zip Code:48178-8614
Mailing Address - Country:US
Mailing Address - Phone:248-259-6364
Mailing Address - Fax:
Practice Address - Street 1:620 BYRON RD
Practice Address - Street 2:
Practice Address - City:HOWELL
Practice Address - State:MI
Practice Address - Zip Code:48843-1002
Practice Address - Country:US
Practice Address - Phone:248-259-6364
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704210153363LA2100X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4721491Medicaid
P1768001Medicare ID - Type Unspecified
P84871Medicare UPIN