Provider Demographics
NPI:1992040737
Name:WIDENER, ELAINE B
Entity Type:Individual
Prefix:MRS
First Name:ELAINE
Middle Name:B
Last Name:WIDENER
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 1:5871 GROVELAND STATION RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT MORRIS
Mailing Address - State:NY
Mailing Address - Zip Code:14510-9767
Mailing Address - Country:US
Mailing Address - Phone:585-658-4023
Mailing Address - Fax:
Practice Address - Street 1:5871 GROVELAND STATION RD
Practice Address - Street 2:
Practice Address - City:MOUNT MORRIS
Practice Address - State:NY
Practice Address - Zip Code:14510-9767
Practice Address - Country:US
Practice Address - Phone:585-658-4023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-05
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY073359841174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY073359841OtherNEW YORK STATE EDUCATION DEPARTMENT