Provider Demographics
NPI:1831636687
Name:ELLIOTT, NANCY
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:
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 1:1729 VALDEZ DR NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87112-4857
Mailing Address - Country:US
Mailing Address - Phone:505-323-1726
Mailing Address - Fax:
Practice Address - Street 1:8300 CONSTITUTION NE
Practice Address - Street 2:ROOM 1303
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110
Practice Address - Country:US
Practice Address - Phone:505-559-5606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-31
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR56893261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care