=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720801350
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NURTURE FAMILY HEALTH NP, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/04/2024
-----------------------------------------------------
Last Update Date | 12/20/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 255 BROADWAY
-----------------------------------------------------
City | LYNBROOK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11563-3243
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-527-3399
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 121 MAIN ST # 1019
-----------------------------------------------------
City | NORTHPORT
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11768-1721
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-527-3399
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MRS. EILEEN MELENDEZ-RIVAS
-----------------------------------------------------
Credential | NURSE PRACTITIONER
-----------------------------------------------------
Telephone | 631-527-3399
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------