Provider Demographics
NPI:1710594403
Name:ELLIOTT, MARY JOSEPHINE (PA-C)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:JOSEPHINE
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 CLAPBOARD HILL RD.
Mailing Address - Street 2:STE 2
Mailing Address - City:GUILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06437
Mailing Address - Country:US
Mailing Address - Phone:203-789-2255
Mailing Address - Fax:203-495-1888
Practice Address - Street 1:47 CLAPBOARD HILL RD.
Practice Address - Street 2:STE 2
Practice Address - City:GUILFORD
Practice Address - State:CT
Practice Address - Zip Code:06437
Practice Address - Country:US
Practice Address - Phone:203-533-7159
Practice Address - Fax:203-533-7161
Is Sole Proprietor?:No
Enumeration Date:2020-09-26
Last Update Date:2025-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
CT5268363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008104362Medicaid