Provider Demographics
NPI:1245313477
Name:ELLIFF, MARY ILEEN (CRNFA)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ILEEN
Last Name:ELLIFF
Suffix:
Gender:F
Credentials:CRNFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1288
Mailing Address - Street 2:
Mailing Address - City:HEALDSBURG
Mailing Address - State:CA
Mailing Address - Zip Code:95448
Mailing Address - Country:US
Mailing Address - Phone:707-433-6279
Mailing Address - Fax:707-433-6279
Practice Address - Street 1:76 BROOKWOOD AVE
Practice Address - Street 2:SANTA ROSA AMBULATORY SURGERY CENTER
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404
Practice Address - Country:US
Practice Address - Phone:510-970-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA321165163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant