Healthcare Provider Details

I. General information

NPI: 1912255415
Provider Name (Legal Business Name): JOLENE ANN KNIGHT RN, PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2012
Last Update Date: 10/02/2023
Certification Date: 10/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

227 COMMACK RD
MASTIC BEACH NY
11951-3427
US

IV. Provider business mailing address

227 COMMACK RD
MASTIC BEACH NY
11951-3427
US

V. Phone/Fax

Practice location:
  • Phone: 631-578-5080
  • Fax:
Mailing address:
  • Phone: 631-578-5080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0600X
TaxonomyGerontology Registered Nurse
License Number759874
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number310830-1
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number405075
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: