Healthcare Provider Details

I. General information

NPI: 1598766388
Provider Name (Legal Business Name): MARY BETH ELLIOTT CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

COUNTRY CLUB ROAD
MONONGAHELA PA
15063
US

IV. Provider business mailing address

204 RODRICK RD
NEW SALEM PA
15468-1214
US

V. Phone/Fax

Practice location:
  • Phone: 724-258-2214
  • Fax:
Mailing address:
  • Phone: 724-245-2239
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN278655L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: