Provider Demographics
NPI:1841961935
Name:WERTIS, ELYSE E
Entity type:Individual
Prefix:
First Name:ELYSE
Middle Name:E
Last Name:WERTIS
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 1:171 ASHLEY AVE # MH383
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29425-0100
Mailing Address - Country:US
Mailing Address - Phone:843-792-8312
Mailing Address - Fax:
Practice Address - Street 1:25 COURTENAY DR
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29425-8911
Practice Address - Country:US
Practice Address - Phone:843-876-4948
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-28
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC00-9564156F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156F00000XEye and Vision Services ProvidersTechnician/Technologist