Provider Demographics
NPI:1902634702
Name:BALASA, ELISE VICTORIA (MSN, CPNP-PC)
Entity type:Individual
Prefix:
First Name:ELISE
Middle Name:VICTORIA
Last Name:BALASA
Suffix:
Gender:
Credentials:MSN, CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4409 SILVERHILL DR
Mailing Address - Street 2:
Mailing Address - City:LAGO VISTA
Mailing Address - State:TX
Mailing Address - Zip Code:78645-6313
Mailing Address - Country:US
Mailing Address - Phone:281-851-3628
Mailing Address - Fax:
Practice Address - Street 1:801 7TH AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2796
Practice Address - Country:US
Practice Address - Phone:682-885-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-23
Last Update Date:2025-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1169378363LP0200X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics