=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811509144
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MANUELA RESTREPO FNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/18/2020
-----------------------------------------------------
Last Update Date | 08/18/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1000 MONTAUK HWY
-----------------------------------------------------
City | WEST ISLIP
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11795-4927
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-376-4045
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 120 SHEFFIELD AVE
-----------------------------------------------------
City | WEST BABYLON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11704-5214
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-707-2447
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | F346442
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------