Provider Demographics
NPI:1740208438
Name:CLOSE, ELISSA (APRN)
Entity type:Individual
Prefix:MS
First Name:ELISSA
Middle Name:
Last Name:CLOSE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3556 VT ROUTE 17
Mailing Address - Street 2:
Mailing Address - City:STARKSBORO
Mailing Address - State:VT
Mailing Address - Zip Code:05487-7178
Mailing Address - Country:US
Mailing Address - Phone:802-453-2330
Mailing Address - Fax:
Practice Address - Street 1:790 COLLEGE PKWY
Practice Address - Street 2:
Practice Address - City:COLCHESTER
Practice Address - State:VT
Practice Address - Zip Code:05446-3007
Practice Address - Country:US
Practice Address - Phone:802-847-7572
Practice Address - Fax:802-847-7559
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT101-0012139363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1011444Medicaid
VT1011444Medicaid