Basic Information
| Provider Information | |||||||||
| NPI: | 1407323132 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLIOTT | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | JANE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DNP, APRN, FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1008 S SPRING AVE FL 2 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631102520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149778462 | ||||||||
| FaxNumber: | 3149773370 | ||||||||
| Practice Location | |||||||||
| Address1: | 1201 S GRAND BLVD | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631041016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149778462 | ||||||||
| FaxNumber: | 3149773370 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2018 | ||||||||
| LastUpdateDate: | 03/15/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 2018026391 | MO | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LG0600X | F07181228 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
No ID Information.