Healthcare Provider Details

I. General information

NPI: 1396309092
Provider Name (Legal Business Name): ELANOR PETERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2019
Last Update Date: 03/28/2023
Certification Date: 03/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5992 BERRYHILL RD STE 205
MILTON FL
32570-1014
US

IV. Provider business mailing address

5992 BERRYHILL RD STE 205
MILTON FL
32570-1014
US

V. Phone/Fax

Practice location:
  • Phone: 850-626-5324
  • Fax:
Mailing address:
  • Phone: 850-293-7247
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9112375
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: