Basic Information
| Provider Information | |||||||||
| NPI: | 1629153903 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLETTE | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | JORDAN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WOODLIFF | ||||||||
| OtherFirstName: | ELIZABETH | ||||||||
| OtherMiddleName: | JORDAN | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | NP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2075 GLENN MITCHELL DR | ||||||||
| Address2: | STE 400 | ||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234560179 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7572529365 | ||||||||
| FaxNumber: | 7579627217 | ||||||||
| Practice Location | |||||||||
| Address1: | 844 KEMPSVILLE RD | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235023927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7572610700 | ||||||||
| FaxNumber: | 7579621254 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2006 | ||||||||
| LastUpdateDate: | 12/05/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 0024167146 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.