Provider Demographics
NPI:1689122053
Name:KRILL, JELIENA N (PA-C)
Entity Type:Individual
Prefix:
First Name:JELIENA
Middle Name:N
Last Name:KRILL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JELIENA
Other - Middle Name:
Other - Last Name:COURVILLE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2160 COLONIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1410
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:8931 COLONIAL CENTER DR STE 400
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33905-7809
Practice Address - Country:US
Practice Address - Phone:239-334-6626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-14
Last Update Date:2018-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9109787363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL4928066OtherAETNA
FLP01748831OtherRR MEDICARE
FLOLW1WOtherBCBS
FL018868500Medicaid
FL1408849OtherWELLCARE MEDICARE/MEDICAID
FL398579OtherAVMED
FL0375748OtherCIGNA
FLIT608ZMedicare PIN