Provider Demographics
NPI:1649249178
Name:ELLIOTT, VINCENT THOMAS (RN, MSN)
Entity type:Individual
Prefix:MR
First Name:VINCENT
Middle Name:THOMAS
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:RN, MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121- H PICCADILLY PLACE
Mailing Address - Street 2:
Mailing Address - City:SAN BRUNO
Mailing Address - State:CA
Mailing Address - Zip Code:94066-2117
Mailing Address - Country:US
Mailing Address - Phone:650-952-6692
Mailing Address - Fax:
Practice Address - Street 1:121 PICCADILLY PL
Practice Address - Street 2:
Practice Address - City:SAN BRUNO
Practice Address - State:CA
Practice Address - Zip Code:94066-2117
Practice Address - Country:US
Practice Address - Phone:650-952-6692
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN 310069364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health