Provider Demographics
NPI:1699071100
Name:ELLIOTT, ALICIA A (CNS)
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:A
Last Name:ELLIOTT
Suffix:
Gender:
Credentials:CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1910 ST JOE CTR RD #23
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1910 SAINT JOE CENTER RD STE 23
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-5000
Practice Address - Country:US
Practice Address - Phone:260-414-4025
Practice Address - Fax:260-484-5664
Is Sole Proprietor?:No
Enumeration Date:2011-01-31
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71003708A364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000730490OtherANTHEM
IN201033980Medicaid
IN201033980Medicaid