Healthcare Provider Details

I. General information

NPI: 1821496324
Provider Name (Legal Business Name): JOHN WESLEY ELLIOTT III CPNP-AC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2014
Last Update Date: 09/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 5TH ST S
ST PETERSBURG FL
33701-4804
US

IV. Provider business mailing address

501 6TH AVE S
ST PETERSBURG FL
33701-4634
US

V. Phone/Fax

Practice location:
  • Phone: 727-767-3153
  • Fax: 727-767-2265
Mailing address:
  • Phone: 727-767-3153
  • Fax: 727-767-2265

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0222X
TaxonomyCritical Care Pediatric Nurse Practitioner
License NumberCOA-16296-NP
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberARNP9398367
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: