Healthcare Provider Details

I. General information

NPI: 1215257829
Provider Name (Legal Business Name): JUDITH ELLENA GROSSO SICKLES CPNP-PC, RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS JUDITH ELLENA GROSSO

II. Dates (important events)

Enumeration Date: 06/04/2010
Last Update Date: 03/20/2023
Certification Date: 03/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 MANCHESTER RD STE 105
POUGHKEEPSIE NY
12603-2895
US

IV. Provider business mailing address

70 KILBAR ROAD
HUDSON NY
12534
US

V. Phone/Fax

Practice location:
  • Phone: 845-452-1700
  • Fax:
Mailing address:
  • Phone: 518-221-9122
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number616136-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number616136-1
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number616136
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code363LP0222X
TaxonomyCritical Care Pediatric Nurse Practitioner
License NumberF383023-01
License Number StateNY
# 5
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberF383023-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: