Provider Demographics
NPI:1447625397
Name:HUALLPA, ELIZABETH R
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:R
Last Name:HUALLPA
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 1:3546 104TH ST
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:NY
Mailing Address - Zip Code:11368-1951
Mailing Address - Country:US
Mailing Address - Phone:973-914-1003
Mailing Address - Fax:
Practice Address - Street 1:3546 104TH ST
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:NY
Practice Address - Zip Code:11368-1951
Practice Address - Country:US
Practice Address - Phone:973-914-1003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-03
Last Update Date:2016-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY039802-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY039802-1OtherLICENSE#