Provider Demographics
NPI:1861449787
Name:GILLESPIE, ELIZABETH JAN (CRNA)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:JAN
Last Name:GILLESPIE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:JAN
Other - Last Name:GILLESPIE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNA
Mailing Address - Street 1:3090 COBBLESTONE DR
Mailing Address - Street 2:
Mailing Address - City:PACE
Mailing Address - State:FL
Mailing Address - Zip Code:32571-8425
Mailing Address - Country:US
Mailing Address - Phone:850-995-6193
Mailing Address - Fax:850-995-6193
Practice Address - Street 1:3079 PEACHTREE INDUSTRIAL BLVD
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30097-2215
Practice Address - Country:US
Practice Address - Phone:800-945-6133
Practice Address - Fax:678-546-3606
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2009-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9208292367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG3438OtherBCBS
AL009982125Medicaid
AL59173332OtherBCBS
P00175638OtherPALMETTO GBA-RR MEDICARE
AL59173333OtherBCBS
FL306793900Medicaid
P00175638OtherPALMETTO GBA-RR MEDICARE