Provider Demographics
NPI:1639366842
Name:CLARK, ELISA SUE (LPN)
Entity Type:Individual
Prefix:MS
First Name:ELISA
Middle Name:SUE
Last Name:CLARK
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:ELISA
Other - Middle Name:SUE
Other - Last Name:ROMANO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPN
Mailing Address - Street 1:22 FALMOUTH DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT SINAI
Mailing Address - State:NY
Mailing Address - Zip Code:11766-2722
Mailing Address - Country:US
Mailing Address - Phone:631-642-7564
Mailing Address - Fax:
Practice Address - Street 1:22 FALMOUTH DR
Practice Address - Street 2:
Practice Address - City:MOUNT SINAI
Practice Address - State:NY
Practice Address - Zip Code:11766-2722
Practice Address - Country:US
Practice Address - Phone:631-642-7564
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-02
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY262941164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse