Provider Demographics
NPI:1770057366
Name:DELAROSAMATOS, MYRNA (RN)
Entity type:Individual
Prefix:MS
First Name:MYRNA
Middle Name:
Last Name:DELAROSAMATOS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1463 BRENTWOOD RD
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-4431
Mailing Address - Country:US
Mailing Address - Phone:631-968-1133
Mailing Address - Fax:
Practice Address - Street 1:45 BROOK AVE
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-7416
Practice Address - Country:US
Practice Address - Phone:631-968-1133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-16
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY464567163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool