Provider Demographics
NPI:1295013134
Name:SANSCULOTTE, AUDREY (ANP)
Entity Type:Individual
Prefix:MS
First Name:AUDREY
Middle Name:
Last Name:SANSCULOTTE
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:904 SMITH ST
Mailing Address - Street 2:
Mailing Address - City:UNIONDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11553-3507
Mailing Address - Country:US
Mailing Address - Phone:516-481-6327
Mailing Address - Fax:
Practice Address - Street 1:215 ROCKAWAY TPKE
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:NY
Practice Address - Zip Code:11559-1216
Practice Address - Country:US
Practice Address - Phone:516-374-5024
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-26
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY305815363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health