Basic Information
Provider Information | |||||||||
NPI: | 1649248964 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ELLIOTT | ||||||||
FirstName: | JOY | ||||||||
MiddleName: | COBURN | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | COBURN | ||||||||
OtherFirstName: | JOY | ||||||||
OtherMiddleName: | MARIE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | CRNA | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 851 TRAFALGAR COURT | ||||||||
Address2: | SUITE 200E | ||||||||
City: | MAITLAND | ||||||||
State: | FL | ||||||||
PostalCode: | 32751 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4076670444 | ||||||||
FaxNumber: | 4076674338 | ||||||||
Practice Location | |||||||||
Address1: | 655 W 8TH ST | ||||||||
Address2: | UFJP ANESTHESIA DEPT. | ||||||||
City: | JACKSONVILLE | ||||||||
State: | FL | ||||||||
PostalCode: | 322096511 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9043935582 | ||||||||
FaxNumber: | 9042444908 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/11/2006 | ||||||||
LastUpdateDate: | 07/12/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | ARNP3244722 | FL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
ID Information
ID | Type | State | Issuer | Description | 000978975D | 05 | GA |   | MEDICAID | 3051633-00 | 05 | FL |   | MEDICAID | 000978975A | 05 | GA |   | MEDICAID |