Provider Demographics
NPI:1902356454
Name:DICLEMENTE, ELAINA (PA-C)
Entity Type:Individual
Prefix:
First Name:ELAINA
Middle Name:
Last Name:DICLEMENTE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:748 ROXBURY CT
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48371-1563
Mailing Address - Country:US
Mailing Address - Phone:248-520-0608
Mailing Address - Fax:
Practice Address - Street 1:44199 DEQUINDRE RD STE 222
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48085-1128
Practice Address - Country:US
Practice Address - Phone:248-879-5570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-08
Last Update Date:2019-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601007990363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical