Provider Demographics
NPI:1063938538
Name:STEFANIDIS, MAUREEN ELIZABETH
Entity type:Individual
Prefix:
First Name:MAUREEN
Middle Name:ELIZABETH
Last Name:STEFANIDIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:MASTIC
Mailing Address - State:NY
Mailing Address - Zip Code:11950-2507
Mailing Address - Country:US
Mailing Address - Phone:631-682-8473
Mailing Address - Fax:
Practice Address - Street 1:145 W MONTAUK HWY
Practice Address - Street 2:
Practice Address - City:HAMPTON BAYS
Practice Address - State:NY
Practice Address - Zip Code:11946-4012
Practice Address - Country:US
Practice Address - Phone:631-728-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-16
Last Update Date:2017-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF308341-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health