Provider Demographics
NPI:1730400482
Name:PORTUONDO-SMITH, ALICIA TAMARA (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:TAMARA
Last Name:PORTUONDO-SMITH
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 1:189 WHEATLEY RD
Mailing Address - Street 2:
Mailing Address - City:GLEN HEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11545-2641
Mailing Address - Country:US
Mailing Address - Phone:516-686-4400
Mailing Address - Fax:
Practice Address - Street 1:189 WHEATLEY RD
Practice Address - Street 2:
Practice Address - City:GLEN HEAD
Practice Address - State:NY
Practice Address - Zip Code:11545-2641
Practice Address - Country:US
Practice Address - Phone:516-686-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-17
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY590004163W00000X
NYF402195-1363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse