Provider Demographics
NPI:1508420514
Name:ANNIS, ELISE
Entity type:Individual
Prefix:
First Name:ELISE
Middle Name:
Last Name:ANNIS
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 1:1 W HALEDON AVE
Mailing Address - Street 2:
Mailing Address - City:HALEDON
Mailing Address - State:NJ
Mailing Address - Zip Code:07508-1373
Mailing Address - Country:US
Mailing Address - Phone:862-562-2090
Mailing Address - Fax:
Practice Address - Street 1:1 W HALEDON AVE
Practice Address - Street 2:
Practice Address - City:HALEDON
Practice Address - State:NJ
Practice Address - Zip Code:07508-1373
Practice Address - Country:US
Practice Address - Phone:862-562-2090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-24
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027497363A00000X
NJ25MP00524600363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant