=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730604646
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANDREA SANCLEMENTE NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/11/2017
-----------------------------------------------------
Last Update Date | 01/14/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 74 COMMERCE AVE STE 1
-----------------------------------------------------
City | RIVERHEAD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11901-3105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-727-3422
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 45 RESEARCH WAY STE 105
-----------------------------------------------------
City | EAST SETAUKET
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11733-6401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-675-2125
-----------------------------------------------------
Fax | 631-675-2624
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LW0102X
-----------------------------------------------------
Taxonomy Name | Women's Health Nurse Practitioner
-----------------------------------------------------
License Number | 421298
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------