Provider Demographics
NPI:1891718771
Name:ELTON-LACASSE, CHARISSA (NP-C)
Entity Type:Individual
Prefix:
First Name:CHARISSA
Middle Name:
Last Name:ELTON-LACASSE
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:843 YELLOW TAVERN CT
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-1648
Mailing Address - Country:US
Mailing Address - Phone:214-686-8564
Mailing Address - Fax:
Practice Address - Street 1:3500 I-30 BOX
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:78185-1672
Practice Address - Country:US
Practice Address - Phone:972-698-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX605266363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX605266OtherNURSE PRACTITIONERS