Healthcare Provider Details

I. General information

NPI: 1871290205
Provider Name (Legal Business Name): DONNA MICELI LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2023
Last Update Date: 02/15/2023
Certification Date: 02/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 BELLE TERRE RD BLDG J
PRT JEFFERSON NY
11777-1936
US

IV. Provider business mailing address

33 LEEDS BLVD
FARMINGVILLE NY
11738-1147
US

V. Phone/Fax

Practice location:
  • Phone: 631-828-5361
  • Fax:
Mailing address:
  • Phone: 631-645-0006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: