Healthcare Provider Details

I. General information

NPI: 1003391483
Provider Name (Legal Business Name): ANN-MARIE CIVIL FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2018
Last Update Date: 10/21/2022
Certification Date: 10/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19432 111TH AVE
SAINT ALBANS NY
11412-2014
US

IV. Provider business mailing address

19432 111TH AVE
SAINT ALBANS NY
11412-2014
US

V. Phone/Fax

Practice location:
  • Phone: 646-691-6477
  • Fax:
Mailing address:
  • Phone: 646-691-6477
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF343206-01
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberF343206-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: