=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679532352
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARISSA LINDA-KAYE PERSAUD NURSE PRACTITIONER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/21/2006
-----------------------------------------------------
Last Update Date | 04/15/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 300 COMMUNITY DR 5 MONTI
-----------------------------------------------------
City | MANHASSET
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11030-3816
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-562-4330
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1120 CONCORD ST
-----------------------------------------------------
City | FRANKLIN SQUARE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11010-2721
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-775-1344
-----------------------------------------------------
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 | F303609-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------