Provider Demographics
NPI:1508811282
Name:ELLIOTT, NANCY LYNN (MD)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:LYNN
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 NO FULLERTON AVENUE
Mailing Address - Street 2:NANCY L ELLIOTT MD
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-3426
Mailing Address - Country:US
Mailing Address - Phone:973-509-1818
Mailing Address - Fax:973-509-0708
Practice Address - Street 1:37 NO FULLERTON AVENUE
Practice Address - Street 2:MONTCLAIR BREAST CENTER
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-3426
Practice Address - Country:US
Practice Address - Phone:973-509-1818
Practice Address - Fax:973-509-0708
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05164700208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ476046QP4Medicare ID - Type Unspecified
E22077Medicare UPIN