=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114272564
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELISSA LYNNE PIERSE LPN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/20/2012
-----------------------------------------------------
Last Update Date | 07/14/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 402 STATE ROUTE 32 N
-----------------------------------------------------
City | NEW PALTZ
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12561-3040
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-204-1371
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 402 STATE ROUTE 32 N
-----------------------------------------------------
City | NEW PALTZ
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12561-3040
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-204-1371
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 164W00000X
-----------------------------------------------------
Taxonomy Name | Licensed Practical Nurse
-----------------------------------------------------
License Number | 253613-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 091580
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 099338
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------