Healthcare Provider Details

I. General information

NPI: 1023595204
Provider Name (Legal Business Name): MARCELLA MIRTO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2018
Last Update Date: 07/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

259 LAKE RD
PINE PLAINS NY
12567-5556
US

IV. Provider business mailing address

259 LAKE RD
PINE PLAINS NY
12567-5556
US

V. Phone/Fax

Practice location:
  • Phone: 845-901-7669
  • Fax:
Mailing address:
  • Phone: 845-901-7669
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number737787
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number737787
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: