Provider Demographics
NPI:1639896061
Name:JOHNSTON, ELISE NICOLE (PA-C)
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:NICOLE
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12109 COUNTY ROAD 103
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:FL
Mailing Address - Zip Code:34484-2951
Mailing Address - Country:US
Mailing Address - Phone:352-504-4623
Mailing Address - Fax:
Practice Address - Street 1:6811 PALISADES PARK CT STE 1
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-7130
Practice Address - Country:US
Practice Address - Phone:239-533-5177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-26
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9116608363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant