Provider Demographics
NPI:1669758744
Name:FEALY, ELAINA JEAN (PA-C)
Entity type:Individual
Prefix:
First Name:ELAINA
Middle Name:JEAN
Last Name:FEALY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:387 SUMMIT AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10552-2224
Mailing Address - Country:US
Mailing Address - Phone:860-806-0008
Mailing Address - Fax:
Practice Address - Street 1:177 FORT WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3733
Practice Address - Country:US
Practice Address - Phone:860-806-0008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-02
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015284363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant