Provider Demographics
NPI:1528227568
Name:NURSE PRACTITIONER ADULT AND FAMILY SERVICES PLLC
Entity Type:Organization
Organization Name:NURSE PRACTITIONER ADULT AND FAMILY SERVICES PLLC
Other - Org Name:FULTON AVENUE HEALTHCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:SENTELL
Authorized Official - Last Name:HARPER
Authorized Official - Suffix:
Authorized Official - Credentials:ANP
Authorized Official - Phone:516-385-2920
Mailing Address - Street 1:72 FULTON AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:HEMPSTEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11550-3651
Mailing Address - Country:US
Mailing Address - Phone:516-385-2920
Mailing Address - Fax:516-385-2293
Practice Address - Street 1:72 FULTON AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:HEMPSTEAD
Practice Address - State:NY
Practice Address - Zip Code:11550-3651
Practice Address - Country:US
Practice Address - Phone:516-385-2920
Practice Address - Fax:516-385-2293
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-05
Last Update Date:2010-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY300692363LA2200X
NY333895363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01973380Medicaid
NY02739480Medicaid
NYS92783Medicare UPIN
NYQ76357Medicare UPIN
NY02739480Medicaid
NY92N611Medicare PIN