Provider Demographics
NPI:1790851814
Name:RAPHAELIDIS, LEIA (NP)
Entity Type:Individual
Prefix:
First Name:LEIA
Middle Name:
Last Name:RAPHAELIDIS
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 1:620 W SENECA ST
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-3326
Mailing Address - Country:US
Mailing Address - Phone:607-273-1513
Mailing Address - Fax:607-273-8776
Practice Address - Street 1:620 W SENECA ST
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-3326
Practice Address - Country:US
Practice Address - Phone:607-273-1513
Practice Address - Fax:607-273-8776
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2014-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF333784363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00362863Medicaid