Provider Demographics
NPI:1447733811
Name:ELLIOTT, KIA (NP)
Entity type:Individual
Prefix:
First Name:KIA
Middle Name:
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 HOSPITAL RD STE 101
Mailing Address - Street 2:
Mailing Address - City:PRINCE FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:20678-4019
Mailing Address - Country:US
Mailing Address - Phone:410-414-2778
Mailing Address - Fax:443-899-1038
Practice Address - Street 1:110 HOSPITAL RD STE 101
Practice Address - Street 2:
Practice Address - City:PRINCE FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:20678-4019
Practice Address - Country:US
Practice Address - Phone:410-535-8119
Practice Address - Fax:443-899-1038
Is Sole Proprietor?:No
Enumeration Date:2018-09-12
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR201699363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner