1821496696 NPI number — DR. ELYSSA JEAN WASHBURN AU.D.

Table of content: DR. ELYSSA JEAN WASHBURN AU.D. (NPI 1821496696)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821496696 NPI number — DR. ELYSSA JEAN WASHBURN AU.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WASHBURN
Provider First Name:
ELYSSA
Provider Middle Name:
JEAN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
AU.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DOOM
Provider Other First Name:
ELYSSA
Provider Other Middle Name:
JEAN
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
AU.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1821496696
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/16/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1125 S BALL ST
Provider Second Line Business Mailing Address:
STE 105
Provider Business Mailing Address City Name:
GRAPEVINE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76051-4038
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-722-6156
Provider Business Mailing Address Fax Number:
817-722-6159

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1125 S BALL ST
Provider Second Line Business Practice Location Address:
STE 105
Provider Business Practice Location Address City Name:
GRAPEVINE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76051-4038
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-722-6156
Provider Business Practice Location Address Fax Number:
817-722-6159
Provider Enumeration Date:
12/10/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 231H00000X , with the licence number:  80854 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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