Provider Demographics
NPI:1740058635
Name:MATA FERMIN, NANCY ALTAGRACIA (NP)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:ALTAGRACIA
Last Name:MATA FERMIN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:NANCY
Other - Middle Name:ALTAGRACIA
Other - Last Name:MATA FERMIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:29 ROSE AVE
Mailing Address - Street 2:
Mailing Address - City:WESTBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11590-1027
Mailing Address - Country:US
Mailing Address - Phone:347-293-3818
Mailing Address - Fax:212-923-5531
Practice Address - Street 1:436 FORT WASHINGTON AVE APT 1H
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10033-3537
Practice Address - Country:US
Practice Address - Phone:347-293-3818
Practice Address - Fax:212-923-5531
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-19
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF353217-01363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty