Healthcare Provider Details

I. General information

NPI: 1891310629
Provider Name (Legal Business Name): NATHALIE DELVA-JEMMOTT NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2020
Last Update Date: 02/20/2021
Certification Date: 02/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 BROOKLYN AVE APT 213
VALLEY STREAM NY
11581-1253
US

IV. Provider business mailing address

7404 5TH AVE
BROOKLYN NY
11209-2704
US

V. Phone/Fax

Practice location:
  • Phone: 516-859-7196
  • Fax:
Mailing address:
  • Phone: 718-439-5111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number718449-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: