Provider Demographics
NPI:1366687931
Name:ELMORE, LISA
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:
Last Name:ELMORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8115 164TH ST
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11432-1118
Mailing Address - Country:US
Mailing Address - Phone:718-380-3000
Mailing Address - Fax:718-380-3214
Practice Address - Street 1:8225 164TH ST
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-1120
Practice Address - Country:US
Practice Address - Phone:718-374-0002
Practice Address - Fax:718-380-3214
Is Sole Proprietor?:No
Enumeration Date:2008-12-10
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005079-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist