Healthcare Provider Details

I. General information

NPI: 1679121107
Provider Name (Legal Business Name): MRS. SALEMA SHIRELLE GRIFFITH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2019
Last Update Date: 09/03/2026
Certification Date: 12/01/2020
Deactivation Date: 12/01/2020
Reactivation Date: 09/03/2026

III. Provider practice location address

299 HALLOCK AVE
PORT JEFFERSON STATION NY
11776-1217
US

IV. Provider business mailing address

11 CHANCE PL
WEST BABYLON NY
11704-6409
US

V. Phone/Fax

Practice location:
  • Phone: 631-473-4284
  • Fax:
Mailing address:
  • Phone: 718-813-6294
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number619334121
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: