Provider Demographics
NPI:1902273675
Name:ROUSE, ELISABETH
Entity Type:Individual
Prefix:
First Name:ELISABETH
Middle Name:
Last Name:ROUSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 OAK ST APT A.
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:NY
Mailing Address - Zip Code:13165
Mailing Address - Country:US
Mailing Address - Phone:315-745-9496
Mailing Address - Fax:
Practice Address - Street 1:21 OAK ST APT A.
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:NY
Practice Address - Zip Code:13165
Practice Address - Country:US
Practice Address - Phone:315-745-9496
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-28
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY320345-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse