Healthcare Provider Details

I. General information

NPI: 1538569405
Provider Name (Legal Business Name): TATIANA PORTELA NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2014
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

560 NORTHERN BLVD STE 203
GREAT NECK NY
11021-5113
US

IV. Provider business mailing address

560 NORTHERN BLVD STE 203
GREAT NECK NY
11021-5113
US

V. Phone/Fax

Practice location:
  • Phone: 718-564-0684
  • Fax:
Mailing address:
  • Phone: 516-482-0600
  • Fax: 516-829-9674

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1084853
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: