Provider Demographics
NPI:1194036269
Name:ELLIOTT, AMELIA ELISABETH CANRIGHT (PA)
Entity Type:Individual
Prefix:
First Name:AMELIA
Middle Name:ELISABETH CANRIGHT
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:AMELIA
Other - Middle Name:ELISABETH
Other - Last Name:CANRIGHT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:701 N 1ST ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62781-0001
Mailing Address - Country:US
Mailing Address - Phone:217-788-3891
Mailing Address - Fax:217-788-6459
Practice Address - Street 1:2300 N EDWARD ST
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-4163
Practice Address - Country:US
Practice Address - Phone:217-876-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085003759363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085003759OtherLICENSE
VA0110004231OtherLICENSE