Healthcare Provider Details

I. General information

NPI: 1700030319
Provider Name (Legal Business Name): MARY ANNE SOTO RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2008
Last Update Date: 11/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5045 MAIN BAYVIEW ROAD
SOUTHOLD NY
11971
US

IV. Provider business mailing address

5045 MAIN BAYVIEW RD
SOUTHOLD NY
11971-4829
US

V. Phone/Fax

Practice location:
  • Phone: 631-484-5550
  • Fax:
Mailing address:
  • Phone: 631-484-5550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number6327411
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: