Basic Information
| Provider Information | |||||||||
| NPI: | 1902305584 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LASALLE | ||||||||
| FirstName: | ELLEN | ||||||||
| MiddleName: | |||||||||
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| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 150 HALF HOLLOW RD | ||||||||
| Address2: | |||||||||
| City: | DEER PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117294216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6312743893 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 263 BLUE POINT AVE | ||||||||
| Address2: | |||||||||
| City: | BLUE POINT | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117151224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314196737 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2018 | ||||||||
| LastUpdateDate: | 02/08/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 427018-1 | NY | Y | Nursing Service Providers | Registered Nurse |
No ID Information.