Healthcare Provider Details

I. General information

NPI: 1720453046
Provider Name (Legal Business Name): MGF WELLNESS VISITS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2015
Last Update Date: 12/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1618 PARK ST
ATLANTIC BEACH NY
11509-1520
US

IV. Provider business mailing address

1618 PARK ST
ATLANTIC BEACH NY
11509-1520
US

V. Phone/Fax

Practice location:
  • Phone: 516-451-9355
  • Fax:
Mailing address:
  • Phone: 516-451-9355
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MELANIE GAY FORMAN
Title or Position: ADULT NURSE PRACTITIONER
Credential: NP
Phone: 516-451-9355