Provider Demographics
NPI:1710388319
Name:ELLIANO, NICOLE ANN (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:ANN
Last Name:ELLIANO
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:MRS
Other - First Name:NICOLE
Other - Middle Name:ANN
Other - Last Name:FEENEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHYSICIAN ASSISTANT
Mailing Address - Street 1:75 N COUNTRY RD
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777
Mailing Address - Country:US
Mailing Address - Phone:631-686-7654
Mailing Address - Fax:631-686-7653
Practice Address - Street 1:75 N COUNTRY RD
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777
Practice Address - Country:US
Practice Address - Phone:631-686-7654
Practice Address - Fax:631-686-7653
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-15
Last Update Date:2018-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017982363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical