Healthcare Provider Details

I. General information

NPI: 1639428543
Provider Name (Legal Business Name): PATRICIA A FAELE MS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2012
Last Update Date: 09/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 DEERA LN
FARMINGVILLE NY
11738-4200
US

IV. Provider business mailing address

5 DEERA LN
FARMINGVILLE NY
11738-4200
US

V. Phone/Fax

Practice location:
  • Phone: 631-451-0996
  • Fax:
Mailing address:
  • Phone: 631-451-0996
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number412104921
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number412103921
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number412105921
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: