MEDICARE: LUZ MERY POBLANO RN

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	F358831-01	NY
2	163W00000X	Registered Nurse	657533-1	NY

General Provider Information

NPI Number	:	1477994143
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LUZ MERY POBLANO RN

Provider Business Mailing Address
First Line	:	59 KANSAS AVE
Second Line	:
City	:	BAY SHORE
State	:	NY
Zip	:	11706-5224
Country	:	US
Telephone Number	:	631-793-4899
Fax Number	:

Provider Business Practice Location Address
First Line	:	59 KANSAS AVE
Second Line	:
City	:	BAY SHORE
State	:	NY
Zip	:	11706-5224
Country	:	US
Telephone Number	:	631-793-4899
Fax Number	:

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

Provider Enumeration Date	:	07/10/2013
Last Update Date	:	03/23/2026

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