Provider Demographics
NPI:1265299457
Name:EMMONS, ELIJAH JOHN
Entity type:Individual
Prefix:
First Name:ELIJAH
Middle Name:JOHN
Last Name:EMMONS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 LEWIS RD
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13905-1048
Mailing Address - Country:US
Mailing Address - Phone:607-770-0025
Mailing Address - Fax:
Practice Address - Street 1:156 CORLISS AVE
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790-2060
Practice Address - Country:US
Practice Address - Phone:607-763-6735
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-04
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY818195163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse