=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942945985
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ODELYA TABIBOV FNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/04/2022
-----------------------------------------------------
Last Update Date | 05/04/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 300 COMMUNITY DR
-----------------------------------------------------
City | MANHASSET
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11030-3816
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-562-0100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9946 64TH AVE
-----------------------------------------------------
City | REGO PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11374-2645
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
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 | F345304-01
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------