Healthcare Provider Details

I. General information

NPI: 1942669130
Provider Name (Legal Business Name): CONNIE ELLIOTT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2016
Last Update Date: 06/20/2022
Certification Date: 06/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 W 22ND ST STE 309
ANDERSON IN
46016-4389
US

IV. Provider business mailing address

141 W 22ND ST STE 309
ANDERSON IN
46016-4389
US

V. Phone/Fax

Practice location:
  • Phone: 765-646-8569
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71006017A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: