Provider Demographics
NPI:1689360463
Name:ATI, BERTHA
Entity Type:Individual
Prefix:
First Name:BERTHA
Middle Name:
Last Name:ATI
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 1:89310 CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:CENTRAL ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11722-5218
Mailing Address - Country:US
Mailing Address - Phone:516-408-0435
Mailing Address - Fax:
Practice Address - Street 1:89310 CIRCLE DR
Practice Address - Street 2:
Practice Address - City:CENTRAL ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11722-5218
Practice Address - Country:US
Practice Address - Phone:516-408-0435
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-13
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY336694164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty