Provider Demographics
NPI:1104408251
Name:FISHBURN, ELISABETH RAVEN
Entity type:Individual
Prefix:
First Name:ELISABETH
Middle Name:RAVEN
Last Name:FISHBURN
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 1:624 N BRENTWOOD CT
Mailing Address - Street 2:
Mailing Address - City:CASTLE ROCK
Mailing Address - State:CO
Mailing Address - Zip Code:80104-9791
Mailing Address - Country:US
Mailing Address - Phone:720-206-8939
Mailing Address - Fax:
Practice Address - Street 1:624 N BRENTWOOD CT
Practice Address - Street 2:
Practice Address - City:CASTLE ROCK
Practice Address - State:CO
Practice Address - Zip Code:80104-9791
Practice Address - Country:US
Practice Address - Phone:720-206-8939
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-27
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1665897163WE0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WE0003XNursing Service ProvidersRegistered NurseEmergency