1861852956 NPI number — MISS AUDREY LYN HENDRICKS-ELLISTON

Table of content: MISS AUDREY LYN HENDRICKS-ELLISTON (NPI 1861852956)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861852956 NPI number — MISS AUDREY LYN HENDRICKS-ELLISTON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HENDRICKS-ELLISTON
Provider First Name:
AUDREY
Provider Middle Name:
LYN
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1861852956
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/02/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1103
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRONX
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10466-0563
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-519-0515
Provider Business Mailing Address Fax Number:
718-519-0515

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3511 BARNES AVE
Provider Second Line Business Practice Location Address:
TILDEN TOWERS 1 APT 6G
Provider Business Practice Location Address City Name:
BRONX
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10467-6031
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-519-0515
Provider Business Practice Location Address Fax Number:
718-519-0515
Provider Enumeration Date:
03/02/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 164W00000X , with the licence number:  296537-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 164W00000X , with the licence number: 2965371 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com