Provider Demographics
NPI:1174369201
Name:ELLENBOGEN, NICOLE DANIELLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:DANIELLE
Last Name:ELLENBOGEN
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 1:761 DOWNING ST
Mailing Address - Street 2:
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-2221
Mailing Address - Country:US
Mailing Address - Phone:201-546-4770
Mailing Address - Fax:
Practice Address - Street 1:100 E 77TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10075-1850
Practice Address - Country:US
Practice Address - Phone:212-434-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-08
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical