Healthcare Provider Details

I. General information

NPI: 1407207772
Provider Name (Legal Business Name): NIKKI BEIRNE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2016
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 ROUTE 112
CORAM NY
11727-4116
US

IV. Provider business mailing address

5 DOUGLAS ST
PORT JEFFERSON STATION NY
11776-3371
US

V. Phone/Fax

Practice location:
  • Phone: 631-920-8500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number115108
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: