=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063938538
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MAUREEN ELIZABETH STEFANIDIS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/16/2017
-----------------------------------------------------
Last Update Date | 08/16/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 145 W MONTAUK HWY
-----------------------------------------------------
City | HAMPTON BAYS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11946-4012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-728-4700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 99 WASHINGTON AVE
-----------------------------------------------------
City | MASTIC
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11950-2507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-682-8473
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | F308341-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------