Provider Demographics
NPI:1427796747
Name:IDE, ELIZABETH ANNE
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANNE
Last Name:IDE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 CELEBRATION PL STE 208
Mailing Address - Street 2:
Mailing Address - City:CELEBRATION
Mailing Address - State:FL
Mailing Address - Zip Code:34747-5434
Mailing Address - Country:US
Mailing Address - Phone:877-800-0239
Mailing Address - Fax:407-566-2499
Practice Address - Street 1:410 CELEBRATION PL STE 208
Practice Address - Street 2:
Practice Address - City:CELEBRATION
Practice Address - State:FL
Practice Address - Zip Code:34747-5434
Practice Address - Country:US
Practice Address - Phone:877-800-0239
Practice Address - Fax:407-566-2499
Is Sole Proprietor?:No
Enumeration Date:2022-05-25
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9116249363AM0700X, 363AS0400X
FLPA9116243363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical