Healthcare Provider Details

I. General information

NPI: 1861449787
Provider Name (Legal Business Name): ELIZABETH JAN GILLESPIE CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELIZABETH JAN GILLESPIE CRNA

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 12/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3079 PEACHTREE INDUSTRIAL BLVD
DULUTH GA
30097-2215
US

IV. Provider business mailing address

3090 COBBLESTONE DR
PACE FL
32571-8425
US

V. Phone/Fax

Practice location:
  • Phone: 800-945-6133
  • Fax: 678-546-3606
Mailing address:
  • Phone: 850-995-6193
  • Fax: 850-995-6193

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberARNP9208292
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: