Healthcare Provider Details

I. General information

NPI: 1740263839
Provider Name (Legal Business Name): DANA MATERIA ANCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2005
Last Update Date: 05/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1147 RICHMOND RD
STATEN ISLAND NY
10304-2423
US

IV. Provider business mailing address

1 EDGEWATER ST 6TH FL
STATEN ISLAND NY
10305-4900
US

V. Phone/Fax

Practice location:
  • Phone: 718-816-9056
  • Fax: 718-816-1165
Mailing address:
  • Phone: 718-226-1047
  • Fax: 718-226-1039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberF334092
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: