Healthcare Provider Details

I. General information

NPI: 1619637485
Provider Name (Legal Business Name): KANDIS MCLEAN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2021
Last Update Date: 05/03/2024
Certification Date: 05/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5141 BROADWAY
NEW YORK NY
10043-1010
US

IV. Provider business mailing address

74 DIX HILLS RD
HUNTINGTON NY
11743-5313
US

V. Phone/Fax

Practice location:
  • Phone: 212-932-4200
  • Fax:
Mailing address:
  • Phone: 929-602-8764
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF347490
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: