Healthcare Provider Details

I. General information

NPI: 1053232074
Provider Name (Legal Business Name): MELISSA D KROENCKE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MRS. MELISSA D WASHBURN

II. Dates (important events)

Enumeration Date: 07/24/2026
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

238 W 16TH ST
DEER PARK NY
11729-5818
US

IV. Provider business mailing address

238 W 16TH ST
DEER PARK NY
11729-5818
US

V. Phone/Fax

Practice location:
  • Phone: 631-455-5522
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: