Provider Demographics
NPI:1861852956
Name:HENDRICKS-ELLISTON, AUDREY LYN
Entity Type:Individual
Prefix:MISS
First Name:AUDREY
Middle Name:LYN
Last Name:HENDRICKS-ELLISTON
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:PO BOX 1103
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10466-0563
Mailing Address - Country:US
Mailing Address - Phone:718-519-0515
Mailing Address - Fax:718-519-0515
Practice Address - Street 1:3511 BARNES AVE
Practice Address - Street 2:TILDEN TOWERS 1 APT 6G
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-6031
Practice Address - Country:US
Practice Address - Phone:718-519-0515
Practice Address - Fax:718-519-0515
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-02
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY296537-1164W00000X
NY2965371164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse