Provider Demographics
NPI:1730168774
Name:SCOTT, LORETTA (NP)
Entity type:Individual
Prefix:
First Name:LORETTA
Middle Name:
Last Name:SCOTT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 LEVERETT AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10308-1724
Mailing Address - Country:US
Mailing Address - Phone:718-948-0138
Mailing Address - Fax:
Practice Address - Street 1:275 CASTLETON AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301-2709
Practice Address - Country:US
Practice Address - Phone:718-447-7800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2009-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF302486-1363LA2200X
NYF340378-1363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01951055Medicaid
NY97V011Medicare ID - Type Unspecified
NY01951055Medicaid