Healthcare Provider Details

I. General information

NPI: 1679554885
Provider Name (Legal Business Name): ELAINE MIELCARSKI N.P., C.N.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2005
Last Update Date: 12/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

770 JAMES ST
SYRACUSE NY
13203-2117
US

IV. Provider business mailing address

792 N MAIN ST SUITE 100A
NORTH SYRACUSE NY
13212-1644
US

V. Phone/Fax

Practice location:
  • Phone: 315-422-2222
  • Fax: 315-472-8497
Mailing address:
  • Phone: 315-423-9722
  • Fax: 315-423-9687

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License NumberF360204-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberF000002-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: