Provider Demographics
NPI:1629074372
Name:ELLIOTT-GONZALEZ, ANN CHRISTY (APRN)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:CHRISTY
Last Name:ELLIOTT-GONZALEZ
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:ANN
Other - Middle Name:CHRISTY
Other - Last Name:ELLIOTT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:APRN
Mailing Address - Street 1:PO BOX 950244
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0244
Mailing Address - Country:US
Mailing Address - Phone:502-953-4700
Mailing Address - Fax:502-772-8189
Practice Address - Street 1:2215 PORTLAND AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40212
Practice Address - Country:US
Practice Address - Phone:502-774-8631
Practice Address - Fax:502-776-8912
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2020-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3003190363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY78009511Medicaid
KYP400033619Medicare PIN
KYP66754Medicare UPIN
KYP400033621Medicare PIN