MEDICARE: GIANNA MARIE SANDOMENICO APN

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	26NR18464500	NJ

General Provider Information

NPI Number	:	1407636392
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GIANNA MARIE SANDOMENICO APN

Provider Business Mailing Address
First Line	:	8 POVERSHON RD
Second Line	:
City	:	NUTLEY
State	:	NJ
Zip	:	07110-2005
Country	:	US
Telephone Number	:	201-687-7524
Fax Number	:

Provider Business Practice Location Address
First Line	:	51 JFK PKWY
Second Line	:
City	:	SHORT HILLS
State	:	NJ
Zip	:	07078-2704
Country	:	US
Telephone Number	:	917-582-6622
Fax Number	:	888-974-2142

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

Provider Enumeration Date	:	09/29/2023
Last Update Date	:	09/29/2023

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