Provider Demographics
NPI:1407174956
Name:YAZDANSETA, VESTA (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:VESTA
Middle Name:
Last Name:YAZDANSETA
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-3074
Mailing Address - Country:US
Mailing Address - Phone:631-473-0983
Mailing Address - Fax:
Practice Address - Street 1:29 BRANCH LN
Practice Address - Street 2:
Practice Address - City:EAST SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-3316
Practice Address - Country:US
Practice Address - Phone:631-681-9228
Practice Address - Fax:631-681-9228
Is Sole Proprietor?:No
Enumeration Date:2010-05-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY622666-1163W00000X
NYF307382-1363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYF307382-1Medicaid