=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598420754
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EMILY MONGAN NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/03/2021
-----------------------------------------------------
Last Update Date | 11/03/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1000 MONTAUK HWY
-----------------------------------------------------
City | WEST ISLIP
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11795-4927
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-376-3000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 535 LAKEVIEW AVE
-----------------------------------------------------
City | BAYPORT
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11705-1205
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-521-1608
-----------------------------------------------------
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 | 310317
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------