Basic Information
| Provider Information | |||||||||
| NPI: | 1841436987 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOSSALLATI | ||||||||
| FirstName: | ELISE | ||||||||
| MiddleName: | COURY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | APRN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | COURY-MOSSALLATI | ||||||||
| OtherFirstName: | ELISE | ||||||||
| OtherMiddleName: | MARY | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | FNP | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 9233 N GREEN BAY RD | ||||||||
| Address2: | |||||||||
| City: | BROWN DEER | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532091103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142708150 | ||||||||
| FaxNumber: | 4142708160 | ||||||||
| Practice Location | |||||||||
| Address1: | 9233 N GREEN BAY RD | ||||||||
| Address2: | |||||||||
| City: | BROWN DEER | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532091103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142708150 | ||||||||
| FaxNumber: | 4142708160 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2008 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 7486 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 3810017214 | 05 | WV | MEDICAID |