Provider Demographics
NPI:1891276903
Name:BORST, ELIZABETH GRACE (REGISTERED NURSE)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:GRACE
Last Name:BORST
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8326 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:INTERLAKEN
Mailing Address - State:NY
Mailing Address - Zip Code:14847-9789
Mailing Address - Country:US
Mailing Address - Phone:607-869-9636
Mailing Address - Fax:
Practice Address - Street 1:8326 MAIN ST
Practice Address - Street 2:
Practice Address - City:INTERLAKEN
Practice Address - State:NY
Practice Address - Zip Code:14847-9789
Practice Address - Country:US
Practice Address - Phone:607-869-9636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-27
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY525418163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01427985Medicaid