Healthcare Provider Details

I. General information

NPI: 1972915387
Provider Name (Legal Business Name): SUZANNE MARGARET KONTAK PMHNP-BC, ANP-C, RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2014
Last Update Date: 01/07/2020
Certification Date: 01/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

939 JOHNSON AVE
RONKONKOMA NY
11779-6066
US

IV. Provider business mailing address

939 JOHNSON AVE
RONKONKOMA NY
11779-6066
US

V. Phone/Fax

Practice location:
  • Phone: 631-471-7242
  • Fax: 631-471-5150
Mailing address:
  • Phone: 631-471-7242
  • Fax: 631-471-5150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberF306884-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberF402191-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: