Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 'STUDENT' | NY |
NPI | 1003104712 |
---|---|
Provider Name | Dr. Jennifer Lyles Titus |
First Address | Southampton, NY 11968-5009 |
Second Address | Southampton, NY 11968-2805 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 14/07/2011 |
Last Update Date | 14/07/2011 |