Healthcare Provider Details

I. General information

NPI: 1366761009
Provider Name (Legal Business Name): AMY C. DITTLER PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. AMY C. MACCHIA

II. Dates (important events)

Enumeration Date: 05/20/2010
Last Update Date: 03/25/2020
Certification Date: 03/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 WAVERLY AVE STE 11
PATCHOGUE NY
11772-1555
US

IV. Provider business mailing address

282 AUBORN AVE
SHIRLEY NY
11967-1734
US

V. Phone/Fax

Practice location:
  • Phone: 917-385-9195
  • Fax:
Mailing address:
  • Phone: 917-385-9195
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number639551
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberF402005
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: