Healthcare Provider Details

I. General information

NPI: 1679735096
Provider Name (Legal Business Name): LAUREN NOELLE ELLISTON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2008
Last Update Date: 04/20/2026
Certification Date: 04/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1060 5TH AVE STE 1A
NEW YORK NY
10128-0104
US

IV. Provider business mailing address

130 E 77TH ST
NEW YORK NY
10075-1851
US

V. Phone/Fax

Practice location:
  • Phone: 516-672-2943
  • Fax:
Mailing address:
  • Phone: 516-672-2943
  • Fax: 516-616-1117

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number262869
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: