Provider Demographics
NPI:1598901290
Name:DOUGLASS, ELIZABETH ANN (LMT)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANN
Last Name:DOUGLASS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19810 GOTTARDE RD
Mailing Address - Street 2:
Mailing Address - City:NORTH FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33917-4563
Mailing Address - Country:US
Mailing Address - Phone:239-822-0973
Mailing Address - Fax:
Practice Address - Street 1:6385 PRESIDENTIAL CT
Practice Address - Street 2:SUITE 102
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-3547
Practice Address - Country:US
Practice Address - Phone:239-822-0973
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-30
Last Update Date:2009-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA55210174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist