Provider Demographics
NPI:1629276613
Name:POAGE, ELLEN GORDON (ARNP)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:GORDON
Last Name:POAGE
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 1:2234 COLONIAL BLVD
Mailing Address - Street 2:ATTN: PAYER CONTRACTING & RELATIONS
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1412
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:8660 COLLEGE PKWY
Practice Address - Street 2:SUITE 60
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-4886
Practice Address - Country:US
Practice Address - Phone:239-277-0919
Practice Address - Fax:239-415-4960
Is Sole Proprietor?:No
Enumeration Date:2007-07-11
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP1812112363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP01279998OtherRAILROAD MCR
FLP959926OtherOPTIMUM
FLY4971OtherBCBS OF FL
FLP999557OtherFREEDOM
FL1235753OtherWELLCARE
FL398633OtherAVMED
FL5034309OtherAETNA
FLAG192XMedicare PIN