Healthcare Provider Details

I. General information

NPI: 1265290993
Provider Name (Legal Business Name): AMELIE SOPHIA POLANCO NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2024
Last Update Date: 03/07/2024
Certification Date: 03/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 BRIANNA LN APT 12Q
SECAUCUS NJ
07094-4522
US

IV. Provider business mailing address

5000 BRIANNA LN APT 12Q
SECAUCUS NJ
07094-4522
US

V. Phone/Fax

Practice location:
  • Phone: 347-678-7782
  • Fax:
Mailing address:
  • Phone: 347-678-7782
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number353797
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: