Healthcare Provider Details

I. General information

NPI: 1487470423
Provider Name (Legal Business Name): DYNAMIC FAMILY HEALTH NP PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/25/2024
Last Update Date: 11/25/2024
Certification Date: 11/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 MEDFORD AVE
EAST PATCHOGUE NY
11772-1307
US

IV. Provider business mailing address

13471 BEDELL ST
JAMAICA NY
11434-4551
US

V. Phone/Fax

Practice location:
  • Phone: 929-519-4039
  • Fax:
Mailing address:
  • Phone: 347-759-9040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MR. NICKOLAS NATHANIEL JACKSON
Title or Position: OWNER
Credential: FNP-C
Phone: 347-759-9040