Provider Demographics
NPI:1952074189
Name:CORREA, ANGELICA MANZOLILLO (FNP-C)
Entity Type:Individual
Prefix:
First Name:ANGELICA
Middle Name:MANZOLILLO
Last Name:CORREA
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-8722
Mailing Address - Country:US
Mailing Address - Phone:631-665-4392
Mailing Address - Fax:
Practice Address - Street 1:8 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-8722
Practice Address - Country:US
Practice Address - Phone:631-665-4392
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-25
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF347464-01363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care