Healthcare Provider Details

I. General information

NPI: 1447407044
Provider Name (Legal Business Name): AMY MAZA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2008
Last Update Date: 08/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

71 VALLEY DR
SOUND BEACH NY
11789-1502
US

IV. Provider business mailing address

71 VALLEY DR
SOUND BEACH NY
11789-1502
US

V. Phone/Fax

Practice location:
  • Phone: 631-744-3874
  • Fax:
Mailing address:
  • Phone: 631-744-3874
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number527842
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: