Provider Demographics
NPI:1649715772
Name:ELLIOTT, LATRICIA
Entity type:Individual
Prefix:
First Name:LATRICIA
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 1:37 E MADISON AVE
Mailing Address - Street 2:APT. A
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45504-2254
Mailing Address - Country:US
Mailing Address - Phone:937-591-0728
Mailing Address - Fax:
Practice Address - Street 1:37 E MADISON AVE
Practice Address - Street 2:APT. A
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45504-2254
Practice Address - Country:US
Practice Address - Phone:937-591-0728
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-28
Last Update Date:2016-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker