Healthcare Provider Details

I. General information

NPI: 1588834527
Provider Name (Legal Business Name): TANNIA CUPERTINO MSN, RN, APN-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2008
Last Update Date: 03/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

390 CRYSTAL RUN RD WALLKILL MEDICAL ARTS BUILDING, SUITE 101
MIDDLETOWN NY
10941-4050
US

IV. Provider business mailing address

300 AVENUE L
MATAMORAS PA
18336-1602
US

V. Phone/Fax

Practice location:
  • Phone: 845-695-6884
  • Fax: 845-695-6886
Mailing address:
  • Phone: 570-491-5778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF335385-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: