Provider Demographics
NPI:1700299252
Name:ELLIOTT, ANGELENE
Entity Type:Individual
Prefix:
First Name:ANGELENE
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 1:915 COMMONWEALTH AVE
Mailing Address - Street 2:REAR
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115
Mailing Address - Country:US
Mailing Address - Phone:617-358-3700
Mailing Address - Fax:
Practice Address - Street 1:915 COMMONWEALTH AVE
Practice Address - Street 2:REAR
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115
Practice Address - Country:US
Practice Address - Phone:617-358-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
METP14063390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program