MEDICARE: MIKAYLA ANN SOLLOWAY FNP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	F349116	NY

General Provider Information

NPI Number	:	1174270086
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIKAYLA ANN SOLLOWAY FNP-C

Provider Business Mailing Address
First Line	:	6 WELLNESS WAY STE 201
Second Line	:
City	:	LATHAM
State	:	NY
Zip	:	12110-2156
Country	:	US
Telephone Number	:	518-782-3700
Fax Number	:	518-782-3799

Provider Business Practice Location Address
First Line	:	1882 NEW SCOTLAND RD STE 200
Second Line	:
City	:	SLINGERLANDS
State	:	NY
Zip	:	12159-3627
Country	:	US
Telephone Number	:	518-439-2460
Fax Number	:	518-439-3025

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/10/2022
Last Update Date	:	04/06/2026

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