Healthcare Provider Details

I. General information

NPI: 1417526450
Provider Name (Legal Business Name): ELYSSA K HURLBUT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2021
Last Update Date: 06/23/2021
Certification Date: 06/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 MAMARONECK AVE STE 320
HARRISON NY
10528-1600
US

IV. Provider business mailing address

500 MAMARONECK AVE STE 320
HARRISON NY
10528-1600
US

V. Phone/Fax

Practice location:
  • Phone: 914-673-1686
  • Fax: 914-705-4537
Mailing address:
  • Phone: 914-673-1686
  • Fax: 914-705-4537

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number002401
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: