Provider Demographics
NPI:1740779206
Name:JEAN MARY, ELISA (NP)
Entity Type:Individual
Prefix:
First Name:ELISA
Middle Name:
Last Name:JEAN MARY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:87-08 JUSTICE AVE SUITE CS
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373
Mailing Address - Country:US
Mailing Address - Phone:718-779-9599
Mailing Address - Fax:718-779-9579
Practice Address - Street 1:87-08 JUSTICE AVE SUITE CS
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373
Practice Address - Country:US
Practice Address - Phone:718-779-9599
Practice Address - Fax:718-779-9579
Is Sole Proprietor?:No
Enumeration Date:2018-05-09
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY308410363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner