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General NPI Number Information
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NPI Number | 1992545214
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Entity Type | Organization
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Legal Business Name | HEALTH-BASED PRIMARY CARE
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Dates
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Enumeration Date | 05/27/2024
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Last Update Date | 11/12/2024
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Provider Practice Location Address
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Address Line | 11 GLADYSZ WAY
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City | PORT JEFFERSON
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State | NY
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Zip | 11777-2263
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Country | US
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Telephone | 917-326-1701
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Fax |
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Provider Business Mailing Address
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Address Line | 11 GLADYSZ WAY
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City | PORT JEFFERSON
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State | NY
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Zip | 11777-2263
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | NURSE PRACTITIONER
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Name | SHEREDA LAWRENCE
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Credential |
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Telephone | 917-326-1701
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number |
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License Number State |
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