Healthcare Provider Details

I. General information

NPI: 1841734779
Provider Name (Legal Business Name): ELISABETH JACQUELINE GUILLEMIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2016
Last Update Date: 12/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6573 A1A S
SAINT AUGUSTINE FL
32080-7504
US

IV. Provider business mailing address

33 GROVE AVE APT A
SAINT AUGUSTINE FL
32084-3251
US

V. Phone/Fax

Practice location:
  • Phone: 904-342-7363
  • Fax:
Mailing address:
  • Phone: 575-770-4828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPAT-9109926
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: