Healthcare Provider Details

I. General information

NPI: 1124340641
Provider Name (Legal Business Name): PSYCHIATRIC NURSE PRACTITIONER SERVICES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/25/2010
Last Update Date: 03/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5036 JERICHO TURNPIKE SUITE 203
NORTHPORT NY
11725
US

IV. Provider business mailing address

5036 JERICHO TURNPIKE
NORTHPORT NY
11768
US

V. Phone/Fax

Practice location:
  • Phone: 631-462-5222
  • Fax: 631-462-5258
Mailing address:
  • Phone: 631-462-5222
  • Fax: 631-462-5258

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License Number
License Number State

VIII. Authorized Official

Name: CHERYL MOORE
Title or Position: PSYCHIATRIC NURSE PRACTITIONER
Credential:
Phone: 631-848-7104