Provider Demographics
NPI:1982104386
Name:ELLIOTT, TINA
Entity type:Individual
Prefix:MISS
First Name:TINA
Middle Name:
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 1:1206 N EUCHEE CREEK PL
Mailing Address - Street 2:
Mailing Address - City:SAND SPRINGS
Mailing Address - State:OK
Mailing Address - Zip Code:74063-5705
Mailing Address - Country:US
Mailing Address - Phone:918-605-7083
Mailing Address - Fax:
Practice Address - Street 1:1206 N EUCHEE CREEK PL
Practice Address - Street 2:
Practice Address - City:SAND SPRINGS
Practice Address - State:OK
Practice Address - Zip Code:74063-5705
Practice Address - Country:US
Practice Address - Phone:918-605-7083
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-13
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
$$$$$$$$$OtherNA