Provider Demographics
NPI:1235320888
Name:MANTIS, ELIZABETH MARIA (LPN)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:MARIA
Last Name:MANTIS
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 1:27 BRIAR RD
Mailing Address - Street 2:
Mailing Address - City:MERRICK
Mailing Address - State:NY
Mailing Address - Zip Code:11566-1520
Mailing Address - Country:US
Mailing Address - Phone:516-377-3937
Mailing Address - Fax:516-867-6914
Practice Address - Street 1:51 ST ANDREWS LANE
Practice Address - Street 2:PERRY DRIVAS
Practice Address - City:GLEN COVE
Practice Address - State:NY
Practice Address - Zip Code:11542-2252
Practice Address - Country:US
Practice Address - Phone:516-656-0057
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-08
Last Update Date:2007-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1417841164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02594425Medicaid