Provider Demographics
NPI:1851855266
Name:ELLIOTT, MONA JANE
Entity Type:Individual
Prefix:
First Name:MONA
Middle Name:JANE
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 1:301 N OKLAHOMA AVE
Mailing Address - Street 2:
Mailing Address - City:MANGUM
Mailing Address - State:OK
Mailing Address - Zip Code:73554-3009
Mailing Address - Country:US
Mailing Address - Phone:580-782-3343
Mailing Address - Fax:
Practice Address - Street 1:301 N OKLAHOMA AVE
Practice Address - Street 2:
Practice Address - City:MANGUM
Practice Address - State:OK
Practice Address - Zip Code:73554-3009
Practice Address - Country:US
Practice Address - Phone:580-782-3343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-30
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK736021103OtherPERSONAL CARE