Provider Demographics
NPI:1558576074
Name:ELLIOTT, STEPHANIE (LAT)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 53 BOX 5070
Mailing Address - Street 2:613 RANGER SMITH CT.
Mailing Address - City:HEMPHILL
Mailing Address - State:TX
Mailing Address - Zip Code:75948-9522
Mailing Address - Country:US
Mailing Address - Phone:409-579-2591
Mailing Address - Fax:
Practice Address - Street 1:1000 MILAM ST.
Practice Address - Street 2:
Practice Address - City:HEMPHILL
Practice Address - State:TX
Practice Address - Zip Code:75948
Practice Address - Country:US
Practice Address - Phone:409-787-3371
Practice Address - Fax:409-787-1259
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT1971390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program