Healthcare Provider Details

I. General information

NPI: 1598006660
Provider Name (Legal Business Name): PHELAN ANTONIA CLANCY A.N.P
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2013
Last Update Date: 10/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2336 GRAND CONCOURSE
BRONX NY
10458-6903
US

IV. Provider business mailing address

145 W MONTAUK HWY
HAMPTON BAYS NY
11946-4012
US

V. Phone/Fax

Practice location:
  • Phone: 718-220-0439
  • Fax: 718-933-2914
Mailing address:
  • Phone: 718-220-0439
  • Fax: 718-933-2914

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number6573601
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number306844-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: