Healthcare Provider Details

I. General information

NPI: 1356578348
Provider Name (Legal Business Name): ELIZABETH SOPHIA COLLIE APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELIZABETH SOPHIA COLLIE ARNP

II. Dates (important events)

Enumeration Date: 06/17/2009
Last Update Date: 06/14/2022
Certification Date: 06/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2862 NW SUWANNEE VALLEY RD
LAKE CITY FL
32055-5603
US

IV. Provider business mailing address

9 HEMLOCK CT
OCALA FL
34472-4294
US

V. Phone/Fax

Practice location:
  • Phone: 386-365-5221
  • Fax:
Mailing address:
  • Phone: 386-365-5221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberARNP9203771
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberARNP9203771
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: