Provider Demographics
NPI:1588205025
Name:ITAV-NURSE PRACTITIONER FAMILY HEALTH PLLC
Entity Type:Organization
Organization Name:ITAV-NURSE PRACTITIONER FAMILY HEALTH PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIA
Authorized Official - Middle Name:
Authorized Official - Last Name:KNIGHT-FORBES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-926-3025
Mailing Address - Street 1:455 ALBANY AVE UNIT C
Mailing Address - Street 2:
Mailing Address - City:AMITYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11701-1193
Mailing Address - Country:US
Mailing Address - Phone:631-926-3025
Mailing Address - Fax:
Practice Address - Street 1:455 ALBANY AVE UNIT C
Practice Address - Street 2:
Practice Address - City:AMITYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11701-1193
Practice Address - Country:US
Practice Address - Phone:631-926-3025
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-07
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04391640Medicaid