Healthcare Provider Details

I. General information

NPI: 1134439466
Provider Name (Legal Business Name): ANNI KRISTINE HEGELAND
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2010
Last Update Date: 11/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 BROOKHAVEN DR
SOUND BEACH NY
11789-1214
US

IV. Provider business mailing address

11 BROOKHAVEN DR
SOUND BEACH NY
11789-1214
US

V. Phone/Fax

Practice location:
  • Phone: 631-338-2894
  • Fax:
Mailing address:
  • Phone: 631-338-2894
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number6323511
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number632351-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: