Basic Information
Provider Information | |||||||||
NPI: | 1710388319 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ELLIANO | ||||||||
FirstName: | NICOLE | ||||||||
MiddleName: | ANN | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PHYSICIAN ASSISTANT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | FEENEY | ||||||||
OtherFirstName: | NICOLE | ||||||||
OtherMiddleName: | ANN | ||||||||
OtherNamePrefix: | MRS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PHYSICIAN ASSISTANT | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 75 N COUNTRY RD | ||||||||
Address2: |   | ||||||||
City: | PORT JEFFERSON | ||||||||
State: | NY | ||||||||
PostalCode: | 11777 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6316867654 | ||||||||
FaxNumber: | 6316867653 | ||||||||
Practice Location | |||||||||
Address1: | 75 N COUNTRY RD | ||||||||
Address2: |   | ||||||||
City: | PORT JEFFERSON | ||||||||
State: | NY | ||||||||
PostalCode: | 11777 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6316867654 | ||||||||
FaxNumber: | 6316867653 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/15/2014 | ||||||||
LastUpdateDate: | 08/09/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 017982 | NY | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 017982 | NY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
No ID Information.