Healthcare Provider Details

I. General information

NPI: 1639735681
Provider Name (Legal Business Name): JAGDEV KAUR NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2019
Last Update Date: 05/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 BROADWAY STE 2
AMITYVILLE NY
11701-2719
US

IV. Provider business mailing address

333 BROADWAY STE 2
AMITYVILLE NY
11701-2719
US

V. Phone/Fax

Practice location:
  • Phone: 631-789-2020
  • Fax:
Mailing address:
  • Phone: 631-789-2020
  • Fax: 631-789-5669

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number541992-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: