Basic Information
| Provider Information | |||||||||
| NPI: | 1356854202 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELKS | ||||||||
| FirstName: | MACEY | ||||||||
| MiddleName: | DIANA | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3051 WATSON BLVD STE 525 | ||||||||
| Address2: | |||||||||
| City: | WARNER ROBINS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310938556 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4789534563 | ||||||||
| FaxNumber: | 4789534564 | ||||||||
| Practice Location | |||||||||
| Address1: | 3051 WATSON BLVD STE 525 | ||||||||
| Address2: | |||||||||
| City: | WARNER ROBINS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31093 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4789534563 | ||||||||
| FaxNumber: | 4789534564 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2017 | ||||||||
| LastUpdateDate: | 07/02/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | RN224167 | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LA2100X | RN224167 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
No ID Information.