Provider Demographics
NPI:1568737633
Name:ELLIOTT, LISA (RN)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 WILDWHEAT
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92614-5452
Mailing Address - Country:US
Mailing Address - Phone:949-433-0006
Mailing Address - Fax:
Practice Address - Street 1:5 VIA BELLEZA
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673-6910
Practice Address - Country:US
Practice Address - Phone:714-423-8306
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-21
Last Update Date:2012-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA728355163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse