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General NPI Number Information
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NPI Number | 1720453046
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Entity Type | Organization
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Legal Business Name | MGF WELLNESS VISITS LLC
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Dates
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Enumeration Date | 12/11/2015
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Last Update Date | 12/11/2015
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Provider Practice Location Address
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Address Line | 1618 PARK ST
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City | ATLANTIC BEACH
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State | NY
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Zip | 11509-1520
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Country | US
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Telephone | 516-451-9355
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Fax |
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Provider Business Mailing Address
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Address Line | 1618 PARK ST
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City | ATLANTIC BEACH
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State | NY
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Zip | 11509-1520
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Country | US
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Telephone | 516-451-9355
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Fax |
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Authorized Official
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Title or Position | ADULT NURSE PRACTITIONER
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Name | MELANIE GAY FORMAN
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Credential | NP
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Telephone | 516-451-9355
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LA2200X
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Taxonomy Name | Adult Health Nurse Practitioner
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License Number |
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License Number State |
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