Provider Demographics
NPI:1578697884
Name:MCCLINTOCK, ELISE MARIE (FNP)
Entity Type:Individual
Prefix:MRS
First Name:ELISE
Middle Name:MARIE
Last Name:MCCLINTOCK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:934 NEW YORK STATE ROUTE 9N
Mailing Address - Street 2:
Mailing Address - City:TICONDEROGA
Mailing Address - State:NY
Mailing Address - Zip Code:12883
Mailing Address - Country:US
Mailing Address - Phone:518-585-7739
Mailing Address - Fax:
Practice Address - Street 1:5110 MIDDLEBURY COLLEGE
Practice Address - Street 2:
Practice Address - City:MIDDLEBURY
Practice Address - State:VT
Practice Address - Zip Code:05753
Practice Address - Country:US
Practice Address - Phone:802-443-5135
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT1010022133363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner