Provider Demographics
NPI:1891294229
Name:CUNNINGHAM, ELIZABETH NICOLE (PAC)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:NICOLE
Last Name:CUNNINGHAM
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 S PORTLAND AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11217-1307
Mailing Address - Country:US
Mailing Address - Phone:518-396-7623
Mailing Address - Fax:
Practice Address - Street 1:8 S PORTLAND AVE APT 4
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11217-1307
Practice Address - Country:US
Practice Address - Phone:518-396-7623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-12
Last Update Date:2018-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021784363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant