Provider Demographics
NPI:1710658075
Name:BIANCANIELLO, EDNA MARISELA (AGACNP)
Entity Type:Individual
Prefix:MRS
First Name:EDNA
Middle Name:MARISELA
Last Name:BIANCANIELLO
Suffix:
Gender:F
Credentials:AGACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5329
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-0233
Mailing Address - Country:US
Mailing Address - Phone:631-805-4680
Mailing Address - Fax:
Practice Address - Street 1:39 BRENTWOOD RD
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-8031
Practice Address - Country:US
Practice Address - Phone:631-591-7400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-25
Last Update Date:2021-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF432087363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care