Healthcare Provider Details

I. General information

NPI: 1407856669
Provider Name (Legal Business Name): PRISCILLA LYNNE WIANT-MASKIN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1070 LUTHER RD
EAST GREENBUSH NY
12061-4020
US

IV. Provider business mailing address

366 ELM AVE
DELMAR NY
12054-9731
US

V. Phone/Fax

Practice location:
  • Phone: 518-477-7664
  • Fax:
Mailing address:
  • Phone: 518-475-1190
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF-331050-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: