Healthcare Provider Details

I. General information

NPI: 1265887053
Provider Name (Legal Business Name): ALICIA MYRIE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2016
Last Update Date: 07/02/2021
Certification Date: 07/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

192 LONGFELLOW DR
MASTIC BEACH NY
11951-2224
US

IV. Provider business mailing address

110 BEAVER DAM RD
BROOKHAVEN NY
11719-9719
US

V. Phone/Fax

Practice location:
  • Phone: 631-816-0021
  • Fax:
Mailing address:
  • Phone: 631-286-8100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number603197-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberF308824
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: