Provider Demographics
NPI:1962718916
Name:RAPHAEL, ROSE-THERESE (FNP-BC)
Entity type:Individual
Prefix:MRS
First Name:ROSE-THERESE
Middle Name:
Last Name:RAPHAEL
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 ZECKENDORF BLVD
Mailing Address - Street 2:QUEENS LONG ISLAND MEDICAL GROUP, P.C.
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530-2133
Mailing Address - Country:US
Mailing Address - Phone:516-542-6880
Mailing Address - Fax:516-542-5556
Practice Address - Street 1:260 W SUNRISE HWY
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11581-1011
Practice Address - Country:US
Practice Address - Phone:516-825-3600
Practice Address - Fax:516-872-5137
Is Sole Proprietor?:No
Enumeration Date:2010-08-27
Last Update Date:2014-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF335974-1363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner