Healthcare Provider Details

I. General information

NPI: 1114456795
Provider Name (Legal Business Name): ANA D FORMAN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2017
Last Update Date: 03/28/2022
Certification Date: 03/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1530 FRONT ST
EAST MEADOW NY
11554-2265
US

IV. Provider business mailing address

3268 45TH ST APT 1R
ASTORIA NY
11103-1913
US

V. Phone/Fax

Practice location:
  • Phone: 516-324-7500
  • Fax:
Mailing address:
  • Phone: 917-732-6041
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF340507-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: