Healthcare Provider Details

I. General information

NPI: 1104922244
Provider Name (Legal Business Name): LISA MICHELLE HODGE-SCELSA NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 08/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 MEDFORD AVE ROUTE 112
PATCHOGUE NY
11772-1281
US

IV. Provider business mailing address

280 MONTAUK HWY PO BOX 9182
BAY SHORE NY
11706-8403
US

V. Phone/Fax

Practice location:
  • Phone: 631-758-4444
  • Fax: 631-758-1984
Mailing address:
  • Phone: 631-758-4444
  • Fax: 631-758-1984

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberF301157
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: