Basic Information
| Provider Information | |||||||||
| NPI: | 1700065257 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELLIOTT | ||||||||
| FirstName: | MONICA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3300 S FISKE BLVD | ||||||||
| Address2: | |||||||||
| City: | ROCKLEDGE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329554306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3212685008 | ||||||||
| FaxNumber: | 3219517408 | ||||||||
| Practice Location | |||||||||
| Address1: | 603 N WASHINGTON AVE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | TITUSVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32796 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3212685008 | ||||||||
| FaxNumber: | 3216076690 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2007 | ||||||||
| LastUpdateDate: | 06/22/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA05295 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | FL | MEDICAID | HV363X | 01 | FL | MEDICARE | OTHER |