Provider Demographics
NPI:1407339062
Name:MUGURUSA, STEPHANIE ELIZABETH (FNP, RN, IBCLC)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:ELIZABETH
Last Name:MUGURUSA
Suffix:
Gender:F
Credentials:FNP, RN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 S FULTON ST
Mailing Address - Street 2:
Mailing Address - City:WESTBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11590-5205
Mailing Address - Country:US
Mailing Address - Phone:516-776-2199
Mailing Address - Fax:
Practice Address - Street 1:35 S FULTON ST
Practice Address - Street 2:
Practice Address - City:WESTBURY
Practice Address - State:NY
Practice Address - Zip Code:11590-5205
Practice Address - Country:US
Practice Address - Phone:516-776-2199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-10
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY340394363LF0000X
NY620280163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily