Healthcare Provider Details

I. General information

NPI: 1548916414
Provider Name (Legal Business Name): TRACEY LYNN MESSINA NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2022
Last Update Date: 03/01/2022
Certification Date: 03/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 CEDAR AVE
PATCHOGUE NY
11772-3538
US

IV. Provider business mailing address

112 CEDAR AVE
PATCHOGUE NY
11772-3538
US

V. Phone/Fax

Practice location:
  • Phone: 631-252-2047
  • Fax:
Mailing address:
  • Phone: 631-252-2047
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberF38330501
License Number StateNY

VII. Legacy identifiers

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

# 1
Identifier661462-01
Identifier TypeOTHER
Identifier StateNY
Identifier IssuerSUNY EDUCATION DEPARTMENT OFFICE OF PROFESSIONS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: