Provider Demographics
NPI:1972086098
Name:ELLIOTT, PATRICA DIANE
Entity type:Individual
Prefix:
First Name:PATRICA
Middle Name:DIANE
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 TROSELLO RD
Mailing Address - Street 2:
Mailing Address - City:CORRALES
Mailing Address - State:NM
Mailing Address - Zip Code:87048-6104
Mailing Address - Country:US
Mailing Address - Phone:907-617-5216
Mailing Address - Fax:
Practice Address - Street 1:600 CAMINO ESPANOL NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-5817
Practice Address - Country:US
Practice Address - Phone:505-250-5204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-13
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3988225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist