Healthcare Provider Details

I. General information

NPI: 1689824609
Provider Name (Legal Business Name): ANTHONY FENNELL YOUNG NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2008
Last Update Date: 02/14/2025
Certification Date: 02/14/2025
Deactivation Date: 10/03/2024
Reactivation Date: 02/14/2025

III. Provider practice location address

927 WILLIS AVE
ALBERTSON NY
11507-1924
US

IV. Provider business mailing address

2130 ADAM CLAYTON POWELL JR BLVD APT 5A
NEW YORK NY
10027-3746
US

V. Phone/Fax

Practice location:
  • Phone: 516-271-0004
  • Fax:
Mailing address:
  • Phone: 770-843-9567
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN163001
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberF311930-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: