1447255591 NPI number — MRS. SANDRA E ELLIOTT CNM, MSN

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447255591 NPI number — MRS. SANDRA E ELLIOTT CNM, MSN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELLIOTT
Provider First Name:
SANDRA
Provider Middle Name:
E
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
CNM, MSN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
EATON-RUSSELL
Provider Other First Name:
SANDRA
Provider Other Middle Name:
E
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1447255591
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/06/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
540 S COLLEGE AVE
Provider Second Line Business Mailing Address:
SUITE 130
Provider Business Mailing Address City Name:
NEWARK
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19713-1302
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
302-831-3195
Provider Business Mailing Address Fax Number:
302-831-3193

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
540 S COLLEGE AVE
Provider Second Line Business Practice Location Address:
SUITE 130
Provider Business Practice Location Address City Name:
NEWARK
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19713-1302
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-831-3195
Provider Business Practice Location Address Fax Number:
302-831-3193
Provider Enumeration Date:
06/16/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367A00000X , with the licence number:  LK0000110 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 163W00000X , with the licence number: L10019057 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0001030139 , issued by the state of ( DE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 028791YNMM . This is a "MEDICARE PTAN" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: 2269350000 . This is a "AMERI HEALTH" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: 7423 . This is a "MID-ATLANTIC" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".




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