Provider Demographics
NPI:1396250114
Name:KOLESAR, ELIZABETH ANN (LPN)
Entity type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:ANN
Last Name:KOLESAR
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MS
Other - First Name:ELIZABETH
Other - Middle Name:ANN
Other - Last Name:REVILLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:MADIGAN ARMY MEDICAL CENTER
Mailing Address - Street 2:9040 JACKSON AVE, ATTN: MCHJ-CLQ-C
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98431-1100
Mailing Address - Country:US
Mailing Address - Phone:253-968-3869
Mailing Address - Fax:
Practice Address - Street 1:MADIGAN ARMY MEDICAL CENTER
Practice Address - Street 2:9040 JACKSON AVE, ATTN: MCHJ-CLQ-C
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98374-1100
Practice Address - Country:US
Practice Address - Phone:253-968-3869
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-04
Last Update Date:2017-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALP60330355164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse