Provider Demographics
NPI:1184026254
Name:ANDERSON, ELIZABETH GAYLE (ARNP-C)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:GAYLE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:ARNP-C
Other - Prefix:MS
Other - First Name:LIBBY
Other - Middle Name:GAYLE
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:ARNP-C
Mailing Address - Street 1:1005 MAR WALT DRIVE
Mailing Address - Street 2:INTERNAL MEDICINE DEPARTMENT
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-6796
Mailing Address - Country:US
Mailing Address - Phone:850-863-8202
Mailing Address - Fax:850-862-6148
Practice Address - Street 1:1005 MAR WALT DRIVE
Practice Address - Street 2:CARE COORDINATION DEPARTMENT
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6796
Practice Address - Country:US
Practice Address - Phone:850-863-8202
Practice Address - Fax:850-862-6198
Is Sole Proprietor?:No
Enumeration Date:2014-09-20
Last Update Date:2018-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP3412702363LA2200X, 363LP2300X, 363L00000X, 364SG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No364SG0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014192700Medicaid
FLY0R4TOtherFLORIDA BLUE
FLY0R4TOtherFLORIDA BLUE