Provider Demographics
NPI:1801122676
Name:SPAIN, ELIZABETH ANNE (LPN)
Entity type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:ANNE
Last Name:SPAIN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 65874
Mailing Address - Street 2:
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50265-0874
Mailing Address - Country:US
Mailing Address - Phone:515-360-8607
Mailing Address - Fax:
Practice Address - Street 1:3000 GRAND AVE APT 801
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50312-4263
Practice Address - Country:US
Practice Address - Phone:515-360-8607
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-28
Last Update Date:2021-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAP36621164W00000X, 164W00000X
IA085012471C3402X
IA5947374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No2471C3402XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistRadiography
No374J00000XNursing Service Related ProvidersDoula
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1801122676OtherBLUE CROSS BLUE SHIELD
IA1801122676Medicaid
IA1801122676OtherBLUE CROSS BLUE SHIELD