Provider Demographics
NPI:1396971305
Name:BEAUBRUN, ELYSE D (ARNP)
Entity type:Individual
Prefix:
First Name:ELYSE
Middle Name:D
Last Name:BEAUBRUN
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:PO BOX 16568
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32245-6568
Mailing Address - Country:US
Mailing Address - Phone:904-472-2300
Mailing Address - Fax:904-472-2330
Practice Address - Street 1:4348 SOUTHPOINT BLVD
Practice Address - Street 2:STE 100
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-0986
Practice Address - Country:US
Practice Address - Phone:904-281-1915
Practice Address - Fax:904-281-1119
Is Sole Proprietor?:No
Enumeration Date:2009-06-04
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP3285412363LF0000X
FLARNP 3285412363LX0001X
FLAPRN3285412367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001194000Medicaid
FLCE640ZMedicare PIN