Provider Demographics
NPI:1215690896
Name:TAVERAS, YALISSA (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:YALISSA
Middle Name:
Last Name:TAVERAS
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 MARCUS AVENUE
Mailing Address - Street 2:SUITE W290
Mailing Address - City:LAKE SUCCESS
Mailing Address - State:NY
Mailing Address - Zip Code:11042
Mailing Address - Country:US
Mailing Address - Phone:516-465-5255
Mailing Address - Fax:718-347-2240
Practice Address - Street 1:2001 MARCUS AVENUE
Practice Address - Street 2:SUITE W290
Practice Address - City:LAKE SUCCESS
Practice Address - State:NY
Practice Address - Zip Code:11042
Practice Address - Country:US
Practice Address - Phone:516-465-5255
Practice Address - Fax:718-347-2240
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-20
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY348494363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty