MEDICARE: SEDA ANGELINA PORT NP

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	404487	NY
2	363LA2200X	Adult Health Nurse Practitioner	308735	NY

General Provider Information

NPI Number	:	1447745278
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SEDA ANGELINA PORT NP

Provider Business Mailing Address
First Line	:	428 E HARRISON ST
Second Line	:
City	:	LONG BEACH
State	:	NY
Zip	:	11561-2346
Country	:	US
Telephone Number	:	212-961-6767
Fax Number	:

Provider Business Practice Location Address
First Line	:	428 E HARRISON ST
Second Line	:
City	:	LONG BEACH
State	:	NY
Zip	:	11561-2346
Country	:	US
Telephone Number	:	212-961-6767
Fax Number	:

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

Provider Enumeration Date	:	06/25/2018
Last Update Date	:	10/31/2022

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