Healthcare Provider Details

I. General information

NPI: 1427484369
Provider Name (Legal Business Name): MARIE LESLIE M EXANTUS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2013
Last Update Date: 09/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 NASSAU BLVD
WEST HEMPSTEAD NY
11552-1047
US

IV. Provider business mailing address

125 NASSAU BLVD
WEST HEMPSTEAD NY
11552-1047
US

V. Phone/Fax

Practice location:
  • Phone: 917-513-5910
  • Fax:
Mailing address:
  • Phone: 917-513-5910
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number673099
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: