Healthcare Provider Details

I. General information

NPI: 1497874341
Provider Name (Legal Business Name): JOAN M KOTAN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

689 JERICHO TPKE
HUNTINGTON STATION NY
11746-7501
US

IV. Provider business mailing address

21 NATHAN PL
HUNTINGTON STATION NY
11746-3225
US

V. Phone/Fax

Practice location:
  • Phone: 631-854-4400
  • Fax: 631-854-4411
Mailing address:
  • Phone: 631-421-2062
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number217431-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: