Healthcare Provider Details

I. General information

NPI: 1780268417
Provider Name (Legal Business Name): ELLYN RACHEL PALMER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2021
Last Update Date: 05/09/2021
Certification Date: 05/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

66 VERMONT ST
MELVILLE NY
11747-1649
US

IV. Provider business mailing address

66 VERMONT ST
MELVILLE NY
11747-1649
US

V. Phone/Fax

Practice location:
  • Phone: 631-275-9058
  • Fax:
Mailing address:
  • Phone: 631-275-9058
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: