Healthcare Provider Details

I. General information

NPI: 1548845779
Provider Name (Legal Business Name): HEIDI DAWN ELLIOTT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2021
Last Update Date: 03/09/2021
Certification Date: 03/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1420 3RD ST SE STE 106
PUYALLUP WA
98372-3730
US

IV. Provider business mailing address

1643 BROWNS POINT BLVD
TACOMA WA
98422-2308
US

V. Phone/Fax

Practice location:
  • Phone: 253-202-3495
  • Fax:
Mailing address:
  • Phone: 253-202-3495
  • Fax: 253-944-1320

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WI0500X
TaxonomyInfusion Therapy Registered Nurse
License NumberRN00157846
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: