Provider Demographics
NPI:1346612488
Name:VAN FLORCKE, TESSA RAIS
Entity Type:Individual
Prefix:
First Name:TESSA
Middle Name:RAIS
Last Name:VAN FLORCKE
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 1:202 N DUNTON AVE
Mailing Address - Street 2:
Mailing Address - City:EAST PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-5561
Mailing Address - Country:US
Mailing Address - Phone:631-748-6690
Mailing Address - Fax:
Practice Address - Street 1:1841 BRENTWOOD RD
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717-4625
Practice Address - Country:US
Practice Address - Phone:631-853-4845
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-28
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program