Provider Demographics
NPI:1083906481
Name:MERCOGLIANO, ELIZABETH KETCHAM (RN)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:KETCHAM
Last Name:MERCOGLIANO
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:BETSY
Other - Middle Name:KETCHAM
Other - Last Name:MERCOGLIANO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN, LM
Mailing Address - Street 1:20 ELM ST
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12202-1703
Mailing Address - Country:US
Mailing Address - Phone:518-465-0241
Mailing Address - Fax:
Practice Address - Street 1:20 ELM ST
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12202-1703
Practice Address - Country:US
Practice Address - Phone:518-465-0241
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-04
Last Update Date:2011-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3307271374J00000X
NYF001443176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
No374J00000XNursing Service Related ProvidersDoula