Healthcare Provider Details

I. General information

NPI: 1932817533
Provider Name (Legal Business Name): PROACTIVE ADULT HEALTH NP, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/11/2022
Last Update Date: 11/11/2022
Certification Date: 11/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 LINMOUTH RD
MALVERNE NY
11565-2202
US

IV. Provider business mailing address

PO BOX 292
MALVERNE NY
11565-0292
US

V. Phone/Fax

Practice location:
  • Phone: 516-915-9771
  • Fax:
Mailing address:
  • Phone: 516-915-9771
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. PETER DUPERVAL
Title or Position: OWNER
Credential: NURSE PRACTITIONER
Phone: 516-915-9771