Healthcare Provider Details

I. General information

NPI: 1225716426
Provider Name (Legal Business Name): ELIZABETH ANNE BENNETT-GARGUILO PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2023
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

57 BAY ST
STATEN ISLAND NY
10301-2510
US

IV. Provider business mailing address

PO BOX 5036
WHITE PLAINS NY
10602-5036
US

V. Phone/Fax

Practice location:
  • Phone: 855-681-8700
  • Fax: 845-765-9324
Mailing address:
  • Phone: 914-898-9421
  • Fax: 914-734-8786

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number258625
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number351663
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number26NR19772700
License Number StateNJ
# 4
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number407509
License Number StateNY
# 5
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number26NJ14892400
License Number StateNJ
# 6
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number258624
License Number StateAK
# 7
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number735422
License Number StateNY
# 8
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NJ14892400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: