Healthcare Provider Details

I. General information

NPI: 1184084295
Provider Name (Legal Business Name): NP ON THE GO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2016
Last Update Date: 03/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3444 KNIGHT ST
OCEANSIDE NY
11572-4639
US

IV. Provider business mailing address

3444 KNIGHT ST
OCEANSIDE NY
11572-4639
US

V. Phone/Fax

Practice location:
  • Phone: 917-864-3822
  • Fax: 800-557-3140
Mailing address:
  • Phone: 917-864-3822
  • Fax: 800-557-3140

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberF307201
License Number StateNY

VIII. Authorized Official

Name: LILA SHAMS
Title or Position: NURSE PRACTITIONER
Credential: N.P.
Phone: 917-864-3822