Provider Demographics
NPI:1518079409
Name:DEVOST, ELEANOR W
Entity Type:Individual
Prefix:
First Name:ELEANOR
Middle Name:W
Last Name:DEVOST
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 N TEMPLE AVE
Mailing Address - Street 2:
Mailing Address - City:STARKE
Mailing Address - State:FL
Mailing Address - Zip Code:32091-1960
Mailing Address - Country:US
Mailing Address - Phone:904-964-7732
Mailing Address - Fax:904-964-3024
Practice Address - Street 1:1801 N TEMPLE AVE
Practice Address - Street 2:
Practice Address - City:STARKE
Practice Address - State:FL
Practice Address - Zip Code:32091-1960
Practice Address - Country:US
Practice Address - Phone:904-964-7732
Practice Address - Fax:904-964-3024
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN804082363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL304974400Medicaid
S49897Medicare UPIN
FL304974400Medicaid