Provider Demographics
NPI:1376895854
Name:WEST, ELISA LYNN (LPN)
Entity type:Individual
Prefix:MRS
First Name:ELISA
Middle Name:LYNN
Last Name:WEST
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:536 W MILWAUKEE ST
Mailing Address - Street 2:
Mailing Address - City:STOUGHTON
Mailing Address - State:WI
Mailing Address - Zip Code:53589-2434
Mailing Address - Country:US
Mailing Address - Phone:608-205-2326
Mailing Address - Fax:
Practice Address - Street 1:536 W MILWAUKEE ST
Practice Address - Street 2:
Practice Address - City:STOUGHTON
Practice Address - State:WI
Practice Address - Zip Code:53589-2434
Practice Address - Country:US
Practice Address - Phone:608-205-2326
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-09
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI302455-31164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse