Healthcare Provider Details

I. General information

NPI: 1780807685
Provider Name (Legal Business Name): LESLIE SUSAN CILLIS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

335 GILLETTE AVENUE
BAYPORT NY
11705-1882
US

IV. Provider business mailing address

35 RANDOLPH DRIVE
DIX HILLS NY
11746-8307
US

V. Phone/Fax

Practice location:
  • Phone: 631-472-7624
  • Fax:
Mailing address:
  • Phone: 631-858-0313
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number3152891
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: