Provider Demographics
NPI:1215359542
Name:BOLTON, ELISHA DAWN (LPN)
Entity Type:Individual
Prefix:
First Name:ELISHA
Middle Name:DAWN
Last Name:BOLTON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 LENOX RD
Mailing Address - Street 2:APT. 5D
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11226-2181
Mailing Address - Country:US
Mailing Address - Phone:646-363-2188
Mailing Address - Fax:
Practice Address - Street 1:245 LENOX RD
Practice Address - Street 2:APT. 5D
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11226-2181
Practice Address - Country:US
Practice Address - Phone:646-363-2188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-06
Last Update Date:2014-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY249267-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse