Provider Demographics
NPI:1275247306
Name:ELLIOTT, CHRISTY RENEE (APRN)
Entity Type:Individual
Prefix:
First Name:CHRISTY
Middle Name:RENEE
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JELLICO
Mailing Address - State:TN
Mailing Address - Zip Code:37762-2154
Mailing Address - Country:US
Mailing Address - Phone:423-784-8492
Mailing Address - Fax:
Practice Address - Street 1:402 CUMBERLAND AVE
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:KY
Practice Address - Zip Code:40769-1238
Practice Address - Country:US
Practice Address - Phone:606-549-2656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-12
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1099206163WM0705X
KY34175363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY4004534OtherKY LICENSE
KY7100905220Medicaid