Healthcare Provider Details

I. General information

NPI: 1558882522
Provider Name (Legal Business Name): MILI BIJU NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MILIMOLE SUKUMARAN NURSE PRACTITIONER

II. Dates (important events)

Enumeration Date: 06/29/2017
Last Update Date: 11/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400H HORSEBLOCK ROAD SUITE H
FARMINGVILLE NY
11738
US

IV. Provider business mailing address

400H HORSEBLOCK ROAD SUITE H
FARMINGVILLE NY
11738
US

V. Phone/Fax

Practice location:
  • Phone: 631-451-2211
  • Fax: 631-451-1463
Mailing address:
  • Phone: 631-451-2211
  • Fax: 631-451-1463

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number572244
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number341614
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: