=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770314965
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SANTE PROFESSIONAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/09/2024
-----------------------------------------------------
Last Update Date | 08/09/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19303 UNION TPKE
-----------------------------------------------------
City | FLUSHING
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11366-1874
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-591-5308
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6716 PARSONS BLVD APT 6C
-----------------------------------------------------
City | FRESH MEADOWS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11365-2958
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-516-3964
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | NURSE PRACTITIONER
-----------------------------------------------------
Name | SOPHIA STALEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 323-516-3964
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------