Healthcare Provider Details

I. General information

NPI: 1205076411
Provider Name (Legal Business Name): MARY ANN PESTRAK APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2009
Last Update Date: 09/29/2021
Certification Date: 09/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 HEMPSTEAD AVE STE 154H
ROCKVILLE CENTRE NY
11570-4033
US

IV. Provider business mailing address

3579 WYANET ST
SEAFORD NY
11783-3011
US

V. Phone/Fax

Practice location:
  • Phone: 516-737-7018
  • Fax: 516-331-3175
Mailing address:
  • Phone: 718-526-8400
  • Fax: 718-523-3063

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberF401181-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: