Provider Demographics
NPI:1760164016
Name:RAFANLLI-WERTHNER, GLORIA
Entity Type:Individual
Prefix:MRS
First Name:GLORIA
Middle Name:
Last Name:RAFANLLI-WERTHNER
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 1:112 EATONS NECK RD
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11768-1110
Mailing Address - Country:US
Mailing Address - Phone:631-624-4073
Mailing Address - Fax:
Practice Address - Street 1:255 EXECUTIVE DR STE LL105
Practice Address - Street 2:
Practice Address - City:PLAINVIEW
Practice Address - State:NY
Practice Address - Zip Code:11803-1718
Practice Address - Country:US
Practice Address - Phone:516-576-2040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-07
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2569752174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist