Basic Information
| Provider Information | |||||||||
| NPI: | 1396971305 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BEAUBRUN | ||||||||
| FirstName: | ELYSE | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 16568 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322456568 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9044722300 | ||||||||
| FaxNumber: | 9044722330 | ||||||||
| Practice Location | |||||||||
| Address1: | 4348 SOUTHPOINT BLVD | ||||||||
| Address2: | STE 100 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322160986 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042811915 | ||||||||
| FaxNumber: | 9042811119 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2009 | ||||||||
| LastUpdateDate: | 10/07/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | ARNP3285412 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LX0001X | ARNP 3285412 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Obstetrics & Gynecology | 367A00000X | APRN3285412 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 001194000 | 05 | FL | MEDICAID |