Provider Demographics
NPI:1194770271
Name:ICAZA, ELISA ROSARIO (ARNP)
Entity type:Individual
Prefix:
First Name:ELISA
Middle Name:ROSARIO
Last Name:ICAZA
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:ELISA
Other - Middle Name:ROSARIO
Other - Last Name:ICAZA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:1700 66TH ST. N.
Mailing Address - Street 2:SUITE 510
Mailing Address - City:ST. PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33710-5512
Mailing Address - Country:US
Mailing Address - Phone:727-384-2479
Mailing Address - Fax:727-384-3573
Practice Address - Street 1:1700 66TH ST. N.
Practice Address - Street 2:SUITE 510
Practice Address - City:ST. PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-5512
Practice Address - Country:US
Practice Address - Phone:727-384-2479
Practice Address - Fax:727-384-3573
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2019-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN1701762363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL304992200Medicaid
FLU4044ZMedicare ID - Type UnspecifiedFL MCR
FL304992200Medicaid