Healthcare Provider Details

I. General information

NPI: 1447155528
Provider Name (Legal Business Name): ELISHA WORTHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2026
Last Update Date: 10/09/2026
Certification Date: 10/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4594 ONONDAGA BLVD APT 38
SYRACUSE NY
13219-3312
US

IV. Provider business mailing address

4594 ONONDAGA BLVD APT 38
SYRACUSE NY
13219-3312
US

V. Phone/Fax

Practice location:
  • Phone: 315-882-3064
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number345647
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: