Provider Demographics
NPI:1972025187
Name:WASSENAAR, ELIZABETH (DOCTOR OF OPTOMETRY)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:WASSENAAR
Suffix:
Gender:F
Credentials:DOCTOR OF OPTOMETRY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:246 POWER ST APT 1
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-3834
Mailing Address - Country:US
Mailing Address - Phone:312-301-7446
Mailing Address - Fax:
Practice Address - Street 1:150 E MANNING ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906
Practice Address - Country:US
Practice Address - Phone:401-272-2020
Practice Address - Fax:401-421-5979
Is Sole Proprietor?:No
Enumeration Date:2017-07-10
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
RIODTG00654152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program