Provider Demographics
NPI:1881793271
Name:ELLIOTT, AUDREY NISSEN (MPT)
Entity type:Individual
Prefix:MRS
First Name:AUDREY
Middle Name:NISSEN
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1678 PARTRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93405-6318
Mailing Address - Country:US
Mailing Address - Phone:805-235-5054
Mailing Address - Fax:
Practice Address - Street 1:1072 LOS OSOS VALLEY RD
Practice Address - Street 2:
Practice Address - City:LOS OSOS
Practice Address - State:CA
Practice Address - Zip Code:93402-3237
Practice Address - Country:US
Practice Address - Phone:805-528-2590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23891225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist