Healthcare Provider Details

I. General information

NPI: 1811237506
Provider Name (Legal Business Name): RACHELLE CONVERSO PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2013
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

257 E JERICHO TPKE
HUNTINGTON STATION NY
11746-7338
US

IV. Provider business mailing address

257 E JERICHO TPKE
HUNTINGTON STATION NY
11746-7338
US

V. Phone/Fax

Practice location:
  • Phone: 631-424-6707
  • Fax: 631-203-2590
Mailing address:
  • Phone: 631-424-6707
  • Fax: 631-203-2590

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number016416
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: