Provider Demographics
NPI:1215569041
Name:SMITHTOWN FAMILY WELLNESS NP PC
Entity Type:Organization
Organization Name:SMITHTOWN FAMILY WELLNESS NP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE MANAGEMENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TANZA
Authorized Official - Middle Name:
Authorized Official - Last Name:EDWARD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:904-654-2410
Mailing Address - Street 1:665 TREEHOUSE CIR
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32095-6837
Mailing Address - Country:US
Mailing Address - Phone:904-654-2410
Mailing Address - Fax:
Practice Address - Street 1:300 E MAIN ST STE 2
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-2900
Practice Address - Country:US
Practice Address - Phone:904-654-2410
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-10
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty