Healthcare Provider Details

I. General information

NPI: 1881443414
Provider Name (Legal Business Name): STEPHANIE BOLANOS FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2024
Last Update Date: 06/19/2026
Certification Date: 06/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20316 43RD AVE APT 2B
BAYSIDE NY
11361-2544
US

IV. Provider business mailing address

20316 43RD AVE APT 2B
BAYSIDE NY
11361-2544
US

V. Phone/Fax

Practice location:
  • Phone: 516-305-3690
  • Fax:
Mailing address:
  • Phone: 516-305-3690
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF353542
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: