Healthcare Provider Details

I. General information

NPI: 1609867753
Provider Name (Legal Business Name): KRISTIN KAY ELLIOTT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2005
Last Update Date: 10/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 E MAIN ST
CROSBY MN
56441-1645
US

IV. Provider business mailing address

320 E MAIN ST
CROSBY MN
56441-1645
US

V. Phone/Fax

Practice location:
  • Phone: 218-546-8375
  • Fax: 218-546-4400
Mailing address:
  • Phone: 218-546-8375
  • Fax: 218-546-4400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number37113
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: