Provider Demographics
NPI:1063718617
Name:MENGUISTAB, ELSA YEMANE
Entity type:Individual
Prefix:
First Name:ELSA
Middle Name:YEMANE
Last Name:MENGUISTAB
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 REXFORD ST
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14621-2605
Mailing Address - Country:US
Mailing Address - Phone:585-309-2490
Mailing Address - Fax:
Practice Address - Street 1:111 REXFORD ST
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621-2605
Practice Address - Country:US
Practice Address - Phone:585-309-2490
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-30
Last Update Date:2011-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY100300289164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse