=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003233479
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HEATHER A ELLIOTT MSN, NP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/24/2014
-----------------------------------------------------
Last Update Date | 10/15/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1014 ELM AVE
-----------------------------------------------------
City | ROCKY FORD
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81067-1328
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-254-7421
-----------------------------------------------------
Fax | 719-254-6966
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1014 ELM AVE P.O. BOX 590
-----------------------------------------------------
City | ROCKY FORD
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81067-1328
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-254-7421
-----------------------------------------------------
Fax | 719-254-6966
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | APN.0991105-NP
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------