Healthcare Provider Details

I. General information

NPI: 1376416966
Provider Name (Legal Business Name): JIMMY MARSEILLE NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2025
Last Update Date: 10/06/2025
Certification Date: 10/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 12TH AVE
HUNTINGTON STATION NY
11746-2104
US

IV. Provider business mailing address

21 12TH AVE
HUNTINGTON STATION NY
11746-2104
US

V. Phone/Fax

Practice location:
  • Phone: 631-988-0848
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number779861
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2025067416
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: