Provider Demographics
NPI:1841019049
Name:RADIANCE WELLNESS NP IN FAMILY HEALTH PLLC
Entity type:Organization
Organization Name:RADIANCE WELLNESS NP IN FAMILY HEALTH PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:SERGINA
Authorized Official - Middle Name:
Authorized Official - Last Name:JEAN
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:631-796-1888
Mailing Address - Street 1:674 DOGWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN SQUARE
Mailing Address - State:NY
Mailing Address - Zip Code:11010-3247
Mailing Address - Country:US
Mailing Address - Phone:631-796-1888
Mailing Address - Fax:929-290-0328
Practice Address - Street 1:674 DOGWOOD AVE
Practice Address - Street 2:
Practice Address - City:FRANKLIN SQUARE
Practice Address - State:NY
Practice Address - Zip Code:11010-3247
Practice Address - Country:US
Practice Address - Phone:631-796-1888
Practice Address - Fax:929-290-0328
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-07
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04405827Medicaid