Provider Demographics
NPI:1538390521
Name:NISSEN, ELAINE A (FNP)
Entity type:Individual
Prefix:MS
First Name:ELAINE
Middle Name:A
Last Name:NISSEN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 N BEAVER ST
Mailing Address - Street 2:PAYER CREDENTIALING
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-3118
Mailing Address - Country:US
Mailing Address - Phone:928-213-6235
Mailing Address - Fax:928-213-6292
Practice Address - Street 1:1298 W FINNIE FLAT RD
Practice Address - Street 2:
Practice Address - City:CAMP VERDE
Practice Address - State:AZ
Practice Address - Zip Code:86322-5958
Practice Address - Country:US
Practice Address - Phone:928-639-5555
Practice Address - Fax:928-639-5554
Is Sole Proprietor?:No
Enumeration Date:2009-08-07
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN040303163W00000X
AZAP3425363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ454700Medicaid
AZZ154208Medicare PIN