Healthcare Provider Details

I. General information

NPI: 1750868824
Provider Name (Legal Business Name): MICHELLE WINTJEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2018
Last Update Date: 07/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 HOSPITAL RD
PATCHOGUE NY
11772-4897
US

IV. Provider business mailing address

3309 NOYAC RD
SAG HARBOR NY
11963-1919
US

V. Phone/Fax

Practice location:
  • Phone: 631-687-4153
  • Fax: 631-687-4282
Mailing address:
  • Phone: 256-283-2592
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number339924
License Number StateNY

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: