Provider Demographics
NPI:1306218656
Name:ELLICOTT, LAUREN R (APRN)
Entity Type:Individual
Prefix:MS
First Name:LAUREN
Middle Name:R
Last Name:ELLICOTT
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, RN-BC, ACCNS-AG
Mailing Address - Street 1:1222 S ORANGE AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-1215
Mailing Address - Country:US
Mailing Address - Phone:321-841-6444
Mailing Address - Fax:407-650-1307
Practice Address - Street 1:1222 S ORANGE AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-1215
Practice Address - Country:US
Practice Address - Phone:321-841-6444
Practice Address - Fax:407-650-1307
Is Sole Proprietor?:No
Enumeration Date:2015-10-27
Last Update Date:2022-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH364S00000X364S00000X
FLAPRN11017239363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist