1700328515 NPI number — ELISE CHRISTINE BJELICA ARNP

Table of content: ELISE CHRISTINE BJELICA ARNP (NPI 1700328515)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700328515 NPI number — ELISE CHRISTINE BJELICA ARNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BJELICA
Provider First Name:
ELISE
Provider Middle Name:
CHRISTINE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ARNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1700328515
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/14/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
151 SOUTHHALL LN STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MAITLAND
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32751-7172
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-875-2080
Provider Business Mailing Address Fax Number:
407-650-3455

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
202 LAKE MIRIAM DR STE 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKELAND
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33813-2180
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-647-2333
Provider Business Practice Location Address Fax Number:
863-393-1995
Provider Enumeration Date:
11/10/2016

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: 363L00000X , with the licence number:  9303546 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 104096300 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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