Provider Demographics
NPI:1760504971
Name:ELLIOTT, CRYSTAL (CFM)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:CFM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:993 BRAXTON DR
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-6824
Mailing Address - Country:US
Mailing Address - Phone:704-788-7764
Mailing Address - Fax:
Practice Address - Street 1:701 E ROOSEVELT BLVD
Practice Address - Street 2:BUILDING 200 SUITE B
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28112-5170
Practice Address - Country:US
Practice Address - Phone:704-291-2218
Practice Address - Fax:704-291-2241
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7795312Medicaid
NC7702811Medicaid
NC7702811Medicaid