Provider Demographics
NPI:1215278916
Name:WEISE, ELIZABETH V (RN)
Entity type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:V
Last Name:WEISE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2360 MADRID AVE SE
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32909-6427
Mailing Address - Country:US
Mailing Address - Phone:321-956-8141
Mailing Address - Fax:321-768-1220
Practice Address - Street 1:2360 MADRID AVE SE
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32909-6427
Practice Address - Country:US
Practice Address - Phone:321-956-8141
Practice Address - Fax:321-768-1220
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-06
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL9646310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001156500Medicaid