Provider Demographics
NPI:1528698396
Name:LIDGARD, ELENA VITALIEVNA (APRN)
Entity type:Individual
Prefix:
First Name:ELENA
Middle Name:VITALIEVNA
Last Name:LIDGARD
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:347 MONTGOMERY AVE
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34243-1509
Mailing Address - Country:US
Mailing Address - Phone:520-954-8224
Mailing Address - Fax:
Practice Address - Street 1:2020 59TH ST W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209-4669
Practice Address - Country:US
Practice Address - Phone:941-798-6199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-21
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11005829363LA2100X
FLAPRN11005829363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care