Healthcare Provider Details

I. General information

NPI: 1861903759
Provider Name (Legal Business Name): MIREILLE ALTIDORT RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2017
Last Update Date: 12/05/2023
Certification Date: 12/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 1ST AVE
ORANGEBURG NY
10962-1106
US

IV. Provider business mailing address

27 SHARON DR
SPRING VALLEY NY
10977-6030
US

V. Phone/Fax

Practice location:
  • Phone: 845-680-4000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number330047
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number819496
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: