Provider Demographics
NPI:1417378829
Name:FUENTES, ELIZABETH
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:FUENTES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:EVA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:337 BEACH 88TH ST
Mailing Address - Street 2:
Mailing Address - City:ROCKAWAY BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11693-1435
Mailing Address - Country:US
Mailing Address - Phone:646-321-9532
Mailing Address - Fax:
Practice Address - Street 1:337 BEACH 88TH ST
Practice Address - Street 2:
Practice Address - City:ROCKAWAY BEACH
Practice Address - State:NY
Practice Address - Zip Code:11693-1435
Practice Address - Country:US
Practice Address - Phone:646-321-9532
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-02
Last Update Date:2014-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY390228-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse