Provider Demographics
NPI:1184687964
Name:O'BRIEN, ELIZABETH W (NP)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:W
Last Name:O'BRIEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 TAUGHANNOCK BLVD
Mailing Address - Street 2:PO BOX 366
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14851
Mailing Address - Country:US
Mailing Address - Phone:607-277-3257
Mailing Address - Fax:607-277-4056
Practice Address - Street 1:201 DATES DRIVE
Practice Address - Street 2:SUITE 206
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850
Practice Address - Country:US
Practice Address - Phone:607-273-9111
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY301110363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01933559Medicaid
NYS87822Medicare UPIN
NY01933559Medicaid