Provider Demographics
NPI:1710594403
Name:ELLIOTT, MARY JOSEPHINE
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JOSEPHINE
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 BEECHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:CT
Mailing Address - Zip Code:06443-1847
Mailing Address - Country:US
Mailing Address - Phone:860-552-9310
Mailing Address - Fax:
Practice Address - Street 1:250 FLAT ROCK PL
Practice Address - Street 2:
Practice Address - City:WESTBROOK
Practice Address - State:CT
Practice Address - Zip Code:06498-3585
Practice Address - Country:US
Practice Address - Phone:860-358-3640
Practice Address - Fax:860-358-8656
Is Sole Proprietor?:No
Enumeration Date:2020-09-26
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant