Provider Demographics
NPI:1184716367
Name:STICKELMAN, ELISA (ANP)
Entity type:Individual
Prefix:
First Name:ELISA
Middle Name:
Last Name:STICKELMAN
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 RESEARCH WAY
Mailing Address - Street 2:SUITE 008 & 108
Mailing Address - City:EAST SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-6401
Mailing Address - Country:US
Mailing Address - Phone:631-941-2704
Mailing Address - Fax:631-941-2009
Practice Address - Street 1:45 RESEARCH WAY
Practice Address - Street 2:SUITE 008 & 108
Practice Address - City:EAST SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-6401
Practice Address - Country:US
Practice Address - Phone:631-941-2704
Practice Address - Fax:631-941-2009
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2009-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF303865363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ15476Medicare UPIN