Basic Information
| Provider Information | |||||||||
| NPI: | 1922488279 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELZA | ||||||||
| FirstName: | JENELLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1123 BEASER AVE | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548062760 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1615 MAPLE LN | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548063610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7156855400 | ||||||||
| FaxNumber: | 7156855102 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2015 | ||||||||
| LastUpdateDate: | 06/02/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 151450-30 | WI | Y | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | 151450-30 | 01 | WI | LICENSE | OTHER |