Healthcare Provider Details

I. General information

NPI: 1518109065
Provider Name (Legal Business Name): JOAN ELLAZAR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2009
Last Update Date: 06/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

278 1ST AVE
NEW YORK NY
10009-1826
US

IV. Provider business mailing address

278 1ST AVE
NEW YORK NY
10009-1826
US

V. Phone/Fax

Practice location:
  • Phone: 718-441-1111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: