Provider Demographics
NPI:1881114122
Name:AMAVI MEDICAL PLLC
Entity type:Organization
Organization Name:AMAVI MEDICAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LYNNEA
Authorized Official - Middle Name:
Authorized Official - Last Name:VILLANOVA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-931-9430
Mailing Address - Street 1:46 SAINT JOHNS PL APT 2
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11217-3280
Mailing Address - Country:US
Mailing Address - Phone:919-931-9439
Mailing Address - Fax:
Practice Address - Street 1:85 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-8338
Practice Address - Country:US
Practice Address - Phone:631-665-3555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-27
Last Update Date:2017-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY203848261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center