Provider Demographics
NPI:1376308957
Name:DOUGLASS, ELISE R (PMHNP-BC, APRN)
Entity type:Individual
Prefix:
First Name:ELISE
Middle Name:R
Last Name:DOUGLASS
Suffix:
Gender:F
Credentials:PMHNP-BC, APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-1765
Mailing Address - Country:US
Mailing Address - Phone:757-788-0300
Mailing Address - Fax:757-788-0969
Practice Address - Street 1:400 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-1767
Practice Address - Country:US
Practice Address - Phone:757-788-0400
Practice Address - Fax:757-788-0957
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-14
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024189032363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health