Basic Information
| Provider Information | |||||||||
| NPI: | 1972057420 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RAYMOND | ||||||||
| FirstName: | ELSA | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 916 TALON DR | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | O FALLON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622691848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6186288211 | ||||||||
| FaxNumber: | 6186280883 | ||||||||
| Practice Location | |||||||||
| Address1: | 916 TALON DR | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | O FALLON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622691848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6186288211 | ||||||||
| FaxNumber: | 6186280883 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2016 | ||||||||
| LastUpdateDate: | 08/12/2016 | ||||||||
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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 | 363LF0000X | 209014542 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.