Basic Information
| Provider Information | |||||||||
| NPI: | 1952359416 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SCANLON | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | ARNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TIPTON | ||||||||
| OtherFirstName: | ELIZABETH | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 12550 PROFESSIONAL PARK DR. | ||||||||
| Address2: | SUITE 11 | ||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2397682111 | ||||||||
| FaxNumber: | 2394824404 | ||||||||
| Practice Location | |||||||||
| Address1: | 650 DEL PRADO BLVD. | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | CAPE CORAL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33990 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2397682111 | ||||||||
| FaxNumber: | 2394824404 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 04/15/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | RN3265172 | FL | N | Allopathic & Osteopathic Physicians | Pediatrics | 363L00000X | RN3265172 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 302930100 | 05 | FL | MEDICAID |