Provider Demographics
NPI:1235703331
Name:MCELLIGOTT, JENNIFER MARIE (RN)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:MARIE
Last Name:MCELLIGOTT
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 DEVOE AVE
Mailing Address - Street 2:
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10705-4717
Mailing Address - Country:US
Mailing Address - Phone:914-200-8966
Mailing Address - Fax:
Practice Address - Street 1:1500 WATERS PL
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-2723
Practice Address - Country:US
Practice Address - Phone:718-931-0600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-14
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY587717163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1119Medicaid