Healthcare Provider Details

I. General information

NPI: 1295013134
Provider Name (Legal Business Name): AUDREY SANSCULOTTE ANP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2011
Last Update Date: 07/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 ROCKAWAY TPKE
LAWRENCE NY
11559-1216
US

IV. Provider business mailing address

904 SMITH ST
UNIONDALE NY
11553-3507
US

V. Phone/Fax

Practice location:
  • Phone: 516-374-5024
  • Fax:
Mailing address:
  • Phone: 516-481-6327
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number305815
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: