=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043817885
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TOTAL CARE ADULT HEALTH, NP, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/05/2020
-----------------------------------------------------
Last Update Date | 10/07/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1401 JERUSALEM AVE
-----------------------------------------------------
City | MERRICK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11566-1342
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-385-6756
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 995 ORION CT
-----------------------------------------------------
City | MERRICK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11566-1025
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-385-6756
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/AUTHORIZED OFFICIAL
-----------------------------------------------------
Name | MS. AMY NG WALDMAN
-----------------------------------------------------
Credential | FNP
-----------------------------------------------------
Telephone | 347-385-6756
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------