MEDICARE: GLENN DONATELLI

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	363LA2200X	Adult Health Nurse Practitioner	310883	NY

General Provider Information

NPI Number	:	1588372296
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GLENN DONATELLI

Provider Business Mailing Address
First Line	:	43 BROADWAY AVE
Second Line	:
City	:	SAYVILLE
State	:	NY
Zip	:	11782-1601
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	43 BROADWAY AVE
Second Line	:
City	:	SAYVILLE
State	:	NY
Zip	:	11782-1601
Country	:	US
Telephone Number	:	631-398-8568
Fax Number	:

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

Provider Enumeration Date	:	11/10/2022
Last Update Date	:	12/15/2022

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