Provider Demographics
NPI:1649316423
Name:FESMIRE, ELLEN ELIZABETH (CRNFA)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:ELIZABETH
Last Name:FESMIRE
Suffix:
Gender:F
Credentials:CRNFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10110 NW COUNTY ROAD 235
Mailing Address - Street 2:
Mailing Address - City:ALACHUA
Mailing Address - State:FL
Mailing Address - Zip Code:32615-6660
Mailing Address - Country:US
Mailing Address - Phone:386-462-7346
Mailing Address - Fax:386-462-7381
Practice Address - Street 1:10110 NW COUNTY ROAD 235
Practice Address - Street 2:
Practice Address - City:ALACHUA
Practice Address - State:FL
Practice Address - Zip Code:32615-6660
Practice Address - Country:US
Practice Address - Phone:386-462-7346
Practice Address - Fax:386-462-7381
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL897992163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL227801OtherAVMED
FLY4737OtherBLUE CROSS BLUE SHIELD