Provider Demographics
NPI:1023599826
Name:PRANTIC, NEAZUL MOWLA (RN)
Entity type:Individual
Prefix:
First Name:NEAZUL
Middle Name:MOWLA
Last Name:PRANTIC
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17128 103RD RD
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11433-1708
Mailing Address - Country:US
Mailing Address - Phone:646-705-1121
Mailing Address - Fax:
Practice Address - Street 1:17 BANK AVE
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-2703
Practice Address - Country:US
Practice Address - Phone:631-265-5300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-28
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY756149-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse