MEDICARE: RADIANCE WELLNESS NP IN FAMILY HEALTH PLLC

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1841019049
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RADIANCE WELLNESS NP IN FAMILY HEALTH PLLC

Provider Business Mailing Address
First Line	:	674 DOGWOOD AVE
Second Line	:
City	:	FRANKLIN SQUARE
State	:	NY
Zip	:	11010-3247
Country	:	US
Telephone Number	:	631-796-1888
Fax Number	:	929-290-0328

Provider Business Practice Location Address
First Line	:	674 DOGWOOD AVE
Second Line	:
City	:	FRANKLIN SQUARE
State	:	NY
Zip	:	11010-3247
Country	:	US
Telephone Number	:	631-796-1888
Fax Number	:	929-290-0328

Authorized Official
Title or Position	:	FAMILY NURSE PRACTITIONER
Name	:	SERGINA JEAN
Credential	:	NP
Telephone Number	:	631-796-1888

Provider Enumeration Date	:	10/07/2024
Last Update Date	:	10/07/2024

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