Healthcare Provider Details

I. General information

NPI: 1306218656
Provider Name (Legal Business Name): LAUREN R ELLICOTT APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAUREN WALLACE MS, RN-BC, ACCNS-AG

II. Dates (important events)

Enumeration Date: 10/27/2015
Last Update Date: 08/21/2025
Certification Date: 08/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1222 S ORANGE AVE
ORLANDO FL
32806-1215
US

IV. Provider business mailing address

1222 S ORANGE AVE
ORLANDO FL
32806-1215
US

V. Phone/Fax

Practice location:
  • Phone: 321-841-6444
  • Fax: 407-650-1307
Mailing address:
  • Phone: 321-841-6444
  • Fax: 407-650-1307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License Number364S00000X
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAPRN11017239
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: