Healthcare Provider Details

I. General information

NPI: 1790604676
Provider Name (Legal Business Name): ELIZABETH GILL APRN, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2026
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1255 STATE ROAD 60 E STE 100
LAKE WALES FL
33853-4310
US

IV. Provider business mailing address

3512 PINE TREE LOOP
HAINES CITY FL
33844-9299
US

V. Phone/Fax

Practice location:
  • Phone: 863-422-5355
  • Fax:
Mailing address:
  • Phone: 863-632-9049
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11045523
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: