Provider Demographics
NPI:1609766617
Name:PRANCKEVICIUS, ELISHA
Entity type:Individual
Prefix:
First Name:ELISHA
Middle Name:
Last Name:PRANCKEVICIUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4207 S DALE MABRY HWY UNIT 4207
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33611-1434
Mailing Address - Country:US
Mailing Address - Phone:508-868-6328
Mailing Address - Fax:
Practice Address - Street 1:4207 S DALE MABRY HWY UNIT 4207
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33611-1434
Practice Address - Country:US
Practice Address - Phone:508-868-6328
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-09
Last Update Date:2025-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11040737363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care