Healthcare Provider Details

I. General information

NPI: 1538080908
Provider Name (Legal Business Name): IV GLOW AND WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2026
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 CEDAR AVE
MEDFORD NY
11763-3501
US

IV. Provider business mailing address

9 CEDAR AVE
MEDFORD NY
11763-3501
US

V. Phone/Fax

Practice location:
  • Phone: 631-294-9780
  • Fax:
Mailing address:
  • Phone: 631-294-9780
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MRS. NICOLE ASHLEY SIGUENCIA
Title or Position: OWNER/PROVIDER
Credential: NURSE PRACTITIONER
Phone: 631-294-9780