Healthcare Provider Details

I. General information

NPI: 1871854661
Provider Name (Legal Business Name): MRS. MARISSA ELIA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2012
Last Update Date: 06/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 CEDAR ST 302
NEW ROCHELLE NY
10801-5247
US

IV. Provider business mailing address

11 PEARL AVE
WEST HARRISON NY
10604-2520
US

V. Phone/Fax

Practice location:
  • Phone: 914-576-5292
  • Fax: 914-636-5990
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number889046
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: