1699777649 NPI number — MRS. SANDRA L ELLIOTT F.N.P.

Table of content: MRS. SANDRA L ELLIOTT F.N.P. (NPI 1699777649)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699777649 NPI number — MRS. SANDRA L ELLIOTT F.N.P.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELLIOTT
Provider First Name:
SANDRA
Provider Middle Name:
L
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
F.N.P.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1699777649
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/20/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3719 HI DALE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE ORION
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48360-2422
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-391-0114
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
39350 9 MILE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTHVILLE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48167-9164
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-425-5149
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/10/2005

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: 363LF0000X , with the licence number:  4704077181 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4476822 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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