Provider Demographics
NPI:1699777649
Name:ELLIOTT, SANDRA L (FNP)
Entity type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:L
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3719 HI DALE DR
Mailing Address - Street 2:
Mailing Address - City:LAKE ORION
Mailing Address - State:MI
Mailing Address - Zip Code:48360-2422
Mailing Address - Country:US
Mailing Address - Phone:248-391-0114
Mailing Address - Fax:
Practice Address - Street 1:39350 9 MILE RD
Practice Address - Street 2:
Practice Address - City:NORTHVILLE
Practice Address - State:MI
Practice Address - Zip Code:48167-9164
Practice Address - Country:US
Practice Address - Phone:248-425-5149
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2009-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704077181363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4476822Medicaid
MIP34780021Medicare PIN
MI4476822Medicaid
MIS33067Medicare UPIN