Basic Information
| Provider Information | |||||||||
| NPI: | 1558982009 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TATIS | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | JESSICA | ||||||||
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| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TATIS | ||||||||
| OtherFirstName: | ANGELA | ||||||||
| OtherMiddleName: | JESSICA | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 907 BELMORE AVE | ||||||||
| Address2: | |||||||||
| City: | ISLIP TERRACE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117521005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5167650345 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 400 SUNRISE HWY | ||||||||
| Address2: | |||||||||
| City: | AMITYVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117012508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6312644000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2020 | ||||||||
| LastUpdateDate: | 09/29/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 97335 | HI | N | Nursing Service Providers | Registered Nurse | 163W00000X | 322490 | NC | N | Nursing Service Providers | Registered Nurse | 163W00000X | R224983 | MD | N | Nursing Service Providers | Registered Nurse | 163W00000X | 708205-1 | NY | N | Nursing Service Providers | Registered Nurse | 363LP0808X | 403756 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.