Provider Demographics
NPI:1043318546
Name:POLSTON, ELIZABETH ANN (PHD, ARNP, WHNP-BC)
Entity Type:Individual
Prefix:PROF
First Name:ELIZABETH
Middle Name:ANN
Last Name:POLSTON
Suffix:
Gender:F
Credentials:PHD, ARNP, WHNP-BC
Other - Prefix:PROF
Other - First Name:ELIZABETH
Other - Middle Name:ANN
Other - Last Name:KOSTAS-POLSTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD, ARNP, WHNP-BC
Mailing Address - Street 1:2750 GREYHAWK ESTATES LN
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33812-5803
Mailing Address - Country:US
Mailing Address - Phone:417-293-8605
Mailing Address - Fax:
Practice Address - Street 1:1733 LAKELAND HILLS BLVD
Practice Address - Street 2:WOMEN'S CARE FLORIDA, LAKELAND OB-GYN
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-3016
Practice Address - Country:US
Practice Address - Phone:863-688-1528
Practice Address - Fax:863-688-8423
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO143823363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO428958102Medicaid
000080507Medicare ID - Type Unspecified