Healthcare Provider Details

I. General information

NPI: 1356989537
Provider Name (Legal Business Name): ELYSE MARIE FARNSWORTH REGISTERED NURSE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2019
Last Update Date: 12/18/2019
Certification Date: 12/18/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

92 NORTH MAIN STREET
ST. REGIS FALLS NY
12980
US

IV. Provider business mailing address

92 NORTH MAIN STREET
ST. REGIS FALLS NY
12980
US

V. Phone/Fax

Practice location:
  • Phone: 518-856-9421
  • Fax: 518-856-0142
Mailing address:
  • Phone: 518-856-9421
  • Fax: 518-856-0142

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number734152
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: