Healthcare Provider Details

I. General information

NPI: 1760112213
Provider Name (Legal Business Name): SANDRA BOUCICAUT NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2022
Last Update Date: 02/15/2024
Certification Date: 02/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

285 SILLS RD BLDG 5-6
EAST PATCHOGUE NY
11772-4869
US

IV. Provider business mailing address

14 WALL ST FL 9
NEW YORK NY
10005-2178
US

V. Phone/Fax

Practice location:
  • Phone: 631-228-5802
  • Fax: 929-455-9868
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number310360
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: