Healthcare Provider Details

I. General information

NPI: 1083525232
Provider Name (Legal Business Name): CANDACE COAKLEY-ASSEFA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2026
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 E MAIN ST
BAY SHORE NY
11706-8442
US

IV. Provider business mailing address

38 TIMBER RIDGE DR
HOLBROOK NY
11741-4148
US

V. Phone/Fax

Practice location:
  • Phone: 631-665-0027
  • Fax: 631-665-0172
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number616776
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: