Provider Demographics
NPI:1396201190
Name:EIRIKSSON, LIZA ANN (APRN)
Entity Type:Individual
Prefix:
First Name:LIZA
Middle Name:ANN
Last Name:EIRIKSSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1030 TALLOKAS RD
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-5552
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1200 HENLEY LN
Practice Address - Street 2:
Practice Address - City:BAKER
Practice Address - State:FL
Practice Address - Zip Code:32531-2702
Practice Address - Country:US
Practice Address - Phone:850-537-9312
Practice Address - Fax:850-537-9319
Is Sole Proprietor?:No
Enumeration Date:2019-02-16
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11001194363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner