Provider Demographics
NPI:1871684050
Name:ELLIOTT, SANDRA K (FNP-BC)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:K
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:K
Other - Last Name:EMERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1025 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62703-2403
Mailing Address - Country:US
Mailing Address - Phone:217-528-7541
Mailing Address - Fax:
Practice Address - Street 1:775 ENGINEERING DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62703-5909
Practice Address - Country:US
Practice Address - Phone:217-522-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2009-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-003312363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q19754Medicare UPIN