=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114749538
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUSTINE SALAS-MATIONG
-----------------------------------------------------
Gender |
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/28/2024
-----------------------------------------------------
Last Update Date | 01/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 62 N 3RD ST
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11249-4052
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-650-5337
-----------------------------------------------------
Fax | 646-871-6820
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 62 N 3RD ST
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11249-4052
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-650-5337
-----------------------------------------------------
Fax | 646-871-6820
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | F354179-01
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------