Provider Demographics
NPI:1912516071
Name:JOHANNESEN, ELYSSA NICOLE (PHARMD)
Entity Type:Individual
Prefix:
First Name:ELYSSA
Middle Name:NICOLE
Last Name:JOHANNESEN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 W SOUTH HILLS AVE
Mailing Address - Street 2:
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16801-5929
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:400 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:LEWISTOWN
Practice Address - State:PA
Practice Address - Zip Code:17044-1167
Practice Address - Country:US
Practice Address - Phone:717-242-7276
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-24
Last Update Date:2020-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP454685183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist