Provider Demographics
NPI:1790772010
Name:VILLAVICENCIO, ELIZABETH (NURSE PRACT)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:VILLAVICENCIO
Suffix:
Gender:F
Credentials:NURSE PRACT
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:FLINT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NURSE PRACT
Mailing Address - Street 1:2031 FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10303-1796
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:347 EDISON ST
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10306-3034
Practice Address - Country:US
Practice Address - Phone:718-351-1136
Practice Address - Fax:718-667-9711
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2012-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF3814531363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02389417Medicaid
NY1093G1Medicare ID - Type Unspecified
NY02389417Medicaid