=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295492411
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SEASIDE PRIMARY CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/22/2021
-----------------------------------------------------
Last Update Date | 11/22/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 27 EAST AVE
-----------------------------------------------------
City | WESTERLY
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02891-3107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-246-8496
-----------------------------------------------------
Fax | 860-495-5116
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 27 EAST AVE
-----------------------------------------------------
City | WESTERLY
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02891-3107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-246-8496
-----------------------------------------------------
Fax | 860-495-5116
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. DEBRA L FURTADO
-----------------------------------------------------
Credential | DNP,APRN,FNP
-----------------------------------------------------
Telephone | 401-246-8496
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------