Provider Demographics
NPI:1669561916
Name:BERNAL, ELLEN (ARNP)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:BERNAL
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 271308
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33688-1308
Mailing Address - Country:US
Mailing Address - Phone:813-971-3564
Mailing Address - Fax:813-971-4776
Practice Address - Street 1:13801 BRUCE B DOWNS BLVD
Practice Address - Street 2:SUITE 204
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-3946
Practice Address - Country:US
Practice Address - Phone:813-971-3564
Practice Address - Fax:813-971-4776
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2011-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL930472363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL930472OtherLICENSE
FLE27052Medicare ID - Type Unspecified
FLS83114Medicare UPIN