Healthcare Provider Details

I. General information

NPI: 1184687964
Provider Name (Legal Business Name): ELIZABETH W O'BRIEN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 DATES DRIVE SUITE 206
ITHACA NY
14850
US

IV. Provider business mailing address

202 TAUGHANNOCK BLVD PO BOX 366
ITHACA NY
14851
US

V. Phone/Fax

Practice location:
  • Phone: 607-273-9111
  • Fax:
Mailing address:
  • Phone: 607-277-3257
  • Fax: 607-277-4056

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number301110
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: