Provider Demographics
NPI:1417526450
Name:HURLBUT, ELYSSA K
Entity Type:Individual
Prefix:
First Name:ELYSSA
Middle Name:K
Last Name:HURLBUT
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 1:500 MAMARONECK AVE STE 320
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:NY
Mailing Address - Zip Code:10528-1600
Mailing Address - Country:US
Mailing Address - Phone:914-673-1686
Mailing Address - Fax:914-705-4537
Practice Address - Street 1:500 MAMARONECK AVE STE 320
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:NY
Practice Address - Zip Code:10528-1600
Practice Address - Country:US
Practice Address - Phone:914-673-1686
Practice Address - Fax:914-705-4537
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-23
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002401133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty