=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861988537
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GAYLE ELLIOTT FNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/06/2018
-----------------------------------------------------
Last Update Date | 03/20/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 308 GRIFFITH ST
-----------------------------------------------------
City | PINEVILLE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71360-5270
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-528-5000
-----------------------------------------------------
Fax | 318-448-8013
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2900 SAINT MICHAEL DR STE 401
-----------------------------------------------------
City | TEXARKANA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75503-5211
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-614-5367
-----------------------------------------------------
Fax | 903-614-5343
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | AP10054
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------