Healthcare Provider Details

I. General information

NPI: 1770419467
Provider Name (Legal Business Name): DWAYNE A ELLIOTT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2026
Last Update Date: 06/20/2026
Certification Date: 06/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 BURKARTH RD
WARRENSBURG MO
64093-3101
US

IV. Provider business mailing address

14500 WOODSIDE PLACE DR
ALEXANDER AR
72002-1822
US

V. Phone/Fax

Practice location:
  • Phone: 660-747-2500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number227597
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: