Healthcare Provider Details

I. General information

NPI: 1245313477
Provider Name (Legal Business Name): MARY ILEEN ELLIFF CRNFA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

76 BROOKWOOD AVE SANTA ROSA AMBULATORY SURGERY CENTER
SANTA ROSA CA
95404
US

IV. Provider business mailing address

PO BOX 1288
HEALDSBURG CA
95448
US

V. Phone/Fax

Practice location:
  • Phone: 510-970-5000
  • Fax:
Mailing address:
  • Phone: 707-433-6279
  • Fax: 707-433-6279

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number321165
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: