Provider Demographics
NPI:1265503130
Name:ELLIOTT, ERIC (MSN-APRN)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:MSN-APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5111
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-5111
Mailing Address - Country:US
Mailing Address - Phone:660-882-9840
Mailing Address - Fax:660-882-3504
Practice Address - Street 1:2400 BOONSLICK DR
Practice Address - Street 2:
Practice Address - City:BOONVILLE
Practice Address - State:MO
Practice Address - Zip Code:65233-1935
Practice Address - Country:US
Practice Address - Phone:660-882-9840
Practice Address - Fax:660-882-3504
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001021688363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily