Provider Demographics
NPI:1427612050
Name:ELENTERIO, KATELIN L
Entity type:Individual
Prefix:
First Name:KATELIN
Middle Name:L
Last Name:ELENTERIO
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 1:70 N COUNTRY RD STE 201
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-2161
Mailing Address - Country:US
Mailing Address - Phone:631-331-0200
Mailing Address - Fax:
Practice Address - Street 1:70 N COUNTRY RD STE 201
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-2161
Practice Address - Country:US
Practice Address - Phone:631-331-0200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-29
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY542117163W00000X
NY309150363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse