Healthcare Provider Details

I. General information

NPI: 1326461971
Provider Name (Legal Business Name): MICAELLE RESERVE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2014
Last Update Date: 08/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 CLINTON ST
HEMPSTEAD NY
11550-4281
US

IV. Provider business mailing address

59 CLINTON STREET
HEAMPSTEAD NY
11550
US

V. Phone/Fax

Practice location:
  • Phone: 516-933-0485
  • Fax:
Mailing address:
  • Phone: 516-933-0485
  • Fax: 516-933-1923

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number776983
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number317658-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: