Provider Demographics
NPI:1760117394
Name:ELVIDGE, JILLIAN MARIE
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:MARIE
Last Name:ELVIDGE
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 1:102 LITTLE NECK RD
Mailing Address - Street 2:
Mailing Address - City:CENTERPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11721-1619
Mailing Address - Country:US
Mailing Address - Phone:631-546-8374
Mailing Address - Fax:
Practice Address - Street 1:102 LITTLE NECK RD
Practice Address - Street 2:
Practice Address - City:CENTERPORT
Practice Address - State:NY
Practice Address - Zip Code:11721-1619
Practice Address - Country:US
Practice Address - Phone:631-546-8374
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-18
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist