Provider Demographics
NPI:1447652458
Name:ELLIOTT, LISA M (CNP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 E WESTERN RESERVE RD
Mailing Address - Street 2:2ND FL
Mailing Address - City:POLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44514-3358
Mailing Address - Country:US
Mailing Address - Phone:330-954-3363
Mailing Address - Fax:330-729-7701
Practice Address - Street 1:715 E WESTERN RESERVE RD
Practice Address - Street 2:2ND FL
Practice Address - City:POLAND
Practice Address - State:OH
Practice Address - Zip Code:44514-3358
Practice Address - Country:US
Practice Address - Phone:330-954-3363
Practice Address - Fax:330-729-7701
Is Sole Proprietor?:No
Enumeration Date:2014-09-22
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.022926363LA2100X, 363LG0600X, 363LA2200X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0111527Medicaid
OHH403551Medicare UPIN