1164984498 NPI number — GRACE MROZ NP IN PSYCHIATRY PLLC

Table of content: ANGELLY JOY FERRER MIANE (NPI 1689315764)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164984498 NPI number — GRACE MROZ NP IN PSYCHIATRY PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRACE MROZ NP IN PSYCHIATRY PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164984498
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/04/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
450 WAVERLY AVE
Provider Second Line Business Mailing Address:
BUILDING 4 SUITE 11
Provider Business Mailing Address City Name:
PATCHOGUE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11772
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-730-7503
Provider Business Mailing Address Fax Number:
631-307-9422

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
450 WAVERLY AVE
Provider Second Line Business Practice Location Address:
BUILDING 4 SUITE 11
Provider Business Practice Location Address City Name:
PATCHOGUE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11772
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-730-7503
Provider Business Practice Location Address Fax Number:
631-307-9422
Provider Enumeration Date:
04/04/2019

Additional Information

Authorized Official

Authorized Official Last Name:
MROZ
Authorized Official First Name:
GRACE
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
631-730-7503

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com