Provider Demographics
NPI:1043594096
Name:ELLETT, DEBRA
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:
Last Name:ELLETT
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 1:22 PLEASANT AVE
Mailing Address - Street 2:
Mailing Address - City:SCHAGHTICOKE
Mailing Address - State:NY
Mailing Address - Zip Code:12154-3908
Mailing Address - Country:US
Mailing Address - Phone:518-753-4458
Mailing Address - Fax:518-753-7576
Practice Address - Street 1:22 PLEASANT AVE
Practice Address - Street 2:
Practice Address - City:SCHAGHTICOKE
Practice Address - State:NY
Practice Address - Zip Code:12154-3908
Practice Address - Country:US
Practice Address - Phone:518-753-4458
Practice Address - Fax:518-753-7576
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-07
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY318104-1163W00000X, 163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool
No163W00000XNursing Service ProvidersRegistered Nurse