Provider Demographics
NPI:1780364877
Name:CAMPOS, TALITA (NP)
Entity type:Individual
Prefix:
First Name:TALITA
Middle Name:
Last Name:CAMPOS
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 1:3712 108TH ST
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:NY
Mailing Address - Zip Code:11368-2025
Mailing Address - Country:US
Mailing Address - Phone:718-651-4000
Mailing Address - Fax:
Practice Address - Street 1:3712 108TH ST
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:NY
Practice Address - Zip Code:11368-2025
Practice Address - Country:US
Practice Address - Phone:718-651-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-24
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY827539163W00000X
NYF383553-01363LP0200X
NYF383553363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse