Provider Demographics
NPI:1861988537
Name:ELLIOTT, GAYLE (FNP)
Entity type:Individual
Prefix:
First Name:GAYLE
Middle Name:
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:N/A
Other - Middle Name:
Other - Last Name:N/A
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:2900 SAINT MICHAEL DR STE 401
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-5211
Mailing Address - Country:US
Mailing Address - Phone:903-614-5367
Mailing Address - Fax:903-614-5343
Practice Address - Street 1:308 GRIFFITH ST
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:LA
Practice Address - Zip Code:71360-5270
Practice Address - Country:US
Practice Address - Phone:318-528-5000
Practice Address - Fax:318-448-8013
Is Sole Proprietor?:No
Enumeration Date:2018-07-06
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP10054363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2483561Medicaid