Provider Demographics
NPI:1992014864
Name:ELLIOTT, THERESA MARIE (LPN)
Entity Type:Individual
Prefix:MS
First Name:THERESA
Middle Name:MARIE
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:465 45TH ST
Mailing Address - Street 2:
Mailing Address - City:COPIAGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11726-1018
Mailing Address - Country:US
Mailing Address - Phone:516-473-1666
Mailing Address - Fax:631-532-6185
Practice Address - Street 1:465 45TH ST
Practice Address - Street 2:
Practice Address - City:COPIAGUE
Practice Address - State:NY
Practice Address - Zip Code:11726-1018
Practice Address - Country:US
Practice Address - Phone:516-473-1666
Practice Address - Fax:631-532-6185
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-27
Last Update Date:2010-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY299712-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse