Healthcare Provider Details

I. General information

NPI: 1114749538
Provider Name (Legal Business Name): JUSTINE SALAS-MATIONG
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2024
Last Update Date: 01/07/2025
Certification Date: 01/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

62 N 3RD ST
BROOKLYN NY
11249-4052
US

IV. Provider business mailing address

62 N 3RD ST
BROOKLYN NY
11249-4052
US

V. Phone/Fax

Practice location:
  • Phone: 646-650-5337
  • Fax: 646-871-6820
Mailing address:
  • Phone: 646-650-5337
  • Fax: 646-871-6820

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF354179-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: