Healthcare Provider Details

I. General information

NPI: 1720054455
Provider Name (Legal Business Name): ELIZABETH GERTRUDE SALON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2006
Last Update Date: 01/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 TEMPLE ST SUITE 100
OWEGO NY
13827-1421
US

IV. Provider business mailing address

251 CULVER RD
ITHACA NY
14850-8782
US

V. Phone/Fax

Practice location:
  • Phone: 607-687-5616
  • Fax:
Mailing address:
  • Phone: 607-277-2201
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number330406-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: