Healthcare Provider Details

I. General information

NPI: 1407323132
Provider Name (Legal Business Name): SUSAN JANE ELLIOTT DNP, APRN, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2018
Last Update Date: 03/15/2021
Certification Date: 03/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 S GRAND BLVD
SAINT LOUIS MO
63104-1016
US

IV. Provider business mailing address

1008 S SPRING AVE FL 2
SAINT LOUIS MO
63110-2520
US

V. Phone/Fax

Practice location:
  • Phone: 314-977-8462
  • Fax: 314-977-3370
Mailing address:
  • Phone: 314-977-8462
  • Fax: 314-977-3370

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2018026391
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberF07181228
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: