Healthcare Provider Details

I. General information

NPI: 1114152758
Provider Name (Legal Business Name): JERRY G ELLIOTT NP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2009
Last Update Date: 11/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

888 SWIFT BLVD
RICHLAND WA
99352
US

IV. Provider business mailing address

560 GAGE BLVD SUITE 203
RICHLAND WA
99352
US

V. Phone/Fax

Practice location:
  • Phone: 509-946-9611
  • Fax: 509-942-2185
Mailing address:
  • Phone: 509-942-3627
  • Fax: 509-942-2268

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberN-35393
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberNP-917A
License Number StateID
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP60240764
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: