Healthcare Provider Details

I. General information

NPI: 1023015856
Provider Name (Legal Business Name): MARIE OQUENDO-MILLER MSNP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

Provider Other Name: MARIE SANTIAGO MSNP

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 STADIUM ROAD
STONY BROOK NY
11794-0001
US

IV. Provider business mailing address

50 SEQUOIA DR
CORAM NY
11727-2039
US

V. Phone/Fax

Practice location:
  • Phone: 631-632-6738
  • Fax: 631-632-6936
Mailing address:
  • Phone: 631-474-0263
  • Fax: 631-474-2329

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number255406
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: