Provider Demographics
NPI:1124446679
Name:MENGISTU, ELSA
Entity type:Individual
Prefix:
First Name:ELSA
Middle Name:
Last Name:MENGISTU
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 1:108 W 141ST ST
Mailing Address - Street 2:1F
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10030-1804
Mailing Address - Country:US
Mailing Address - Phone:646-500-4936
Mailing Address - Fax:
Practice Address - Street 1:108 W 141ST ST
Practice Address - Street 2:1F
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10030-1804
Practice Address - Country:US
Practice Address - Phone:646-500-4936
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-02
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY680449163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse