Healthcare Provider Details

I. General information

NPI: 1003249368
Provider Name (Legal Business Name): LOTIS GAY PERILLA EDANO APRN, NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2013
Last Update Date: 04/20/2026
Certification Date: 04/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3435 70TH ST
JACKSON HTS NY
11372-1055
US

IV. Provider business mailing address

3435 70TH ST
JACKSON HTS NY
11372-1055
US

V. Phone/Fax

Practice location:
  • Phone: 718-533-0264
  • Fax:
Mailing address:
  • Phone: 718-651-9700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number347651
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberARNP.AP.70023715-NP
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN001551
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: