Provider Demographics
NPI:1083773402
Name:ELLIOT, MARY H (APRN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:H
Last Name:ELLIOT
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:270 GREEN ST
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139-3312
Mailing Address - Country:US
Mailing Address - Phone:617-575-5850
Mailing Address - Fax:617-575-5860
Practice Address - Street 1:270 GREEN ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02139-3312
Practice Address - Country:US
Practice Address - Phone:617-575-5850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA162186363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MANP4096OtherBCBS MA
MA500030727OtherRR MEDICARE
MANP4096OtherBCBS MA
P83151Medicare UPIN