Healthcare Provider Details

I. General information

NPI: 1356813778
Provider Name (Legal Business Name): ELENA ANDREYEVNA HIBBARD ANP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/24/2018
Last Update Date: 12/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

76 VETERANS AVE
BATH NY
14810-0810
US

IV. Provider business mailing address

76 VETERANS AVE
BATH NY
14810-0810
US

V. Phone/Fax

Practice location:
  • Phone: 607-664-4000
  • Fax:
Mailing address:
  • Phone: 607-664-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberF308950
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: