Provider Demographics
NPI:1811550866
Name:GARRETT, ELISA DENISE (AGNP-C)
Entity type:Individual
Prefix:
First Name:ELISA
Middle Name:DENISE
Last Name:GARRETT
Suffix:
Gender:F
Credentials:AGNP-C
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 1193
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-1193
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4488 NE DEVILS LAKE BLVD
Practice Address - Street 2:
Practice Address - City:LINCOLN CITY
Practice Address - State:OR
Practice Address - Zip Code:97367-5065
Practice Address - Country:US
Practice Address - Phone:541-614-0407
Practice Address - Fax:833-973-5262
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-16
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAG03190056363LG0600X
OR201903457NP-PP363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology