Provider Demographics
NPI:1871114694
Name:LOVE, NAOMI ROSE
Entity type:Individual
Prefix:
First Name:NAOMI
Middle Name:ROSE
Last Name:LOVE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 FAIRMOUNT ST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-3504
Mailing Address - Country:US
Mailing Address - Phone:631-827-0323
Mailing Address - Fax:
Practice Address - Street 1:75 FAIRMOUNT ST
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-3504
Practice Address - Country:US
Practice Address - Phone:631-827-0323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-04
Last Update Date:2020-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY711078543OtherDRIVERS LICENSE