Provider Demographics
NPI:1447588678
Name:CARSON, ELLEN JANE (ARNP)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:JANE
Last Name:CARSON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1706 COTTAGESIDE CT
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33510-2747
Mailing Address - Country:US
Mailing Address - Phone:813-654-0136
Mailing Address - Fax:
Practice Address - Street 1:3003 W DR MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:MS-3012
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6307
Practice Address - Country:US
Practice Address - Phone:813-870-4438
Practice Address - Fax:813-870-4153
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-30
Last Update Date:2013-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP1123702363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL005619700Medicaid