Provider Demographics
NPI:1841734779
Name:GUILLEMIN, ELISABETH JACQUELINE
Entity Type:Individual
Prefix:
First Name:ELISABETH
Middle Name:JACQUELINE
Last Name:GUILLEMIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 GROVE AVE
Mailing Address - Street 2:APT A
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32084-3251
Mailing Address - Country:US
Mailing Address - Phone:575-770-4828
Mailing Address - Fax:
Practice Address - Street 1:6573 A1A S
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32080-7504
Practice Address - Country:US
Practice Address - Phone:904-342-7363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-12
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPAT-9109926363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical