Healthcare Provider Details

I. General information

NPI: 1417990250
Provider Name (Legal Business Name): MICHELLE LEE PANNELLA MPT
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 W 71ST ST
NEW YORK NY
10023-3766
US

IV. Provider business mailing address

1099 OTT LN
MERRICK NY
11566-1315
US

V. Phone/Fax

Practice location:
  • Phone: 212-721-6200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number026068
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: