Provider Demographics
NPI:1669160792
Name:ANDERSON, ELISE MARIE (DNP)
Entity type:Individual
Prefix:
First Name:ELISE
Middle Name:MARIE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4619 S RUSSELL ST
Mailing Address - Street 2:
Mailing Address - City:HOLLADAY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-4548
Mailing Address - Country:US
Mailing Address - Phone:801-949-4016
Mailing Address - Fax:
Practice Address - Street 1:500 FOOTHILL DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84148-4548
Practice Address - Country:US
Practice Address - Phone:801-582-1565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-26
Last Update Date:2024-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12096000-3102163W00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No163W00000XNursing Service ProvidersRegistered Nurse