Provider Demographics
NPI:1114299419
Name:ELLIOTT, LUCY (MMS, PA-C, ATC)
Entity type:Individual
Prefix:MS
First Name:LUCY
Middle Name:
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:MMS, PA-C, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 N 7 HILLS RD STE 220
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-4111
Mailing Address - Country:US
Mailing Address - Phone:618-624-6181
Mailing Address - Fax:
Practice Address - Street 1:310 N 7 HILLS RD STE 220
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-4111
Practice Address - Country:US
Practice Address - Phone:618-624-6181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-01
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085004281363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400277275Medicare PIN
ILF400277274Medicare PIN