Basic Information
| Provider Information | |||||||||
| NPI: | 1487696100 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PELLETIER | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 602373 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282602373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282131500 | ||||||||
| FaxNumber: | 8286516570 | ||||||||
| Practice Location | |||||||||
| Address1: | 260 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | BREVARD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287123378 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8288835286 | ||||||||
| FaxNumber: | 8288835393 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2006 | ||||||||
| LastUpdateDate: | 11/04/2016 | ||||||||
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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 | 367500000X | 172424 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | Q49714A | 01 | NC | MEDICARE PTAN | OTHER |