Healthcare Provider Details

I. General information

NPI: 1346780079
Provider Name (Legal Business Name): VIRGINIA MAHNKEN MS, RN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2017
Last Update Date: 02/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 CLUBHOUSE DR
PATCHOGUE NY
11772-8205
US

IV. Provider business mailing address

475 CLUBHOUSE DR
PATCHOGUE NY
11772-8205
US

V. Phone/Fax

Practice location:
  • Phone: 631-317-3085
  • Fax: 631-317-3085
Mailing address:
  • Phone: 631-317-3085
  • Fax: 631-317-3085

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number399791-1
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier163WHO200X
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name: MS. VIRGINIA MAHNKEN
Title or Position: REGISTERED NURSE
Credential: MS, RN
Phone: 631-317-3085