Provider Demographics
NPI:1790473510
Name:ELLIOTT, KATHERINE ELIZABETH
Entity Type:Individual
Prefix:MRS
First Name:KATHERINE
Middle Name:ELIZABETH
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 1:554 FREEDOM TRL
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31525-4712
Mailing Address - Country:US
Mailing Address - Phone:912-713-7778
Mailing Address - Fax:
Practice Address - Street 1:2415 PARKWOOD DR
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-4722
Practice Address - Country:US
Practice Address - Phone:912-713-7778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-28
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11975363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant