Basic Information
| Provider Information | |||||||||
| NPI: | 1336769017 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLIOTT | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | CNMT, RT(N) | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8800 SE 2ND STREET RD | ||||||||
| Address2: | |||||||||
| City: | TRENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326934720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523396327 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1601 SW ARCHER RD | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326081135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523761611 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2020 | ||||||||
| LastUpdateDate: | 04/22/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207U00000X | CRT83090 | FL | Y | Allopathic & Osteopathic Physicians | Nuclear Medicine |
No ID Information.