=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467228429
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROSE MARY JIBIN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/30/2023
-----------------------------------------------------
Last Update Date | 11/30/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 450 LAKEVILLE RD
-----------------------------------------------------
City | NEW HYDE PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11042-1118
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-734-8000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 28 RIBBON ST
-----------------------------------------------------
City | FRANKLIN SQUARE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11010-4304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-215-4117
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | F351200
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------