Healthcare Provider Details

I. General information

NPI: 1043777642
Provider Name (Legal Business Name): CHARLES H L'HOMMEDIEU JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2019
Last Update Date: 03/11/2020
Certification Date: 03/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 CHESTNUT AVE
FARMINGVILLE NY
11738-1709
US

IV. Provider business mailing address

24 CHESTNUT AVE
FARMINGVILLE NY
11738-1709
US

V. Phone/Fax

Practice location:
  • Phone: 631-774-0747
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number402795
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number391345
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: