=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477957934
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELIDALIS R BURGOS APRN, ACNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/13/2014
-----------------------------------------------------
Last Update Date | 01/28/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2415 N ORANGE AVE 700
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32804-5505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-303-2474
-----------------------------------------------------
Fax | 407-303-0680
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2415 N ORANGE AVE 700
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32804-5505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-303-2474
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LG0600X
-----------------------------------------------------
Taxonomy Name | Gerontology Nurse Practitioner
-----------------------------------------------------
License Number | APRN9258820
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LA2100X
-----------------------------------------------------
Taxonomy Name | Acute Care Nurse Practitioner
-----------------------------------------------------
License Number | ARNP 9258820
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------