Healthcare Provider Details

I. General information

NPI: 1295213700
Provider Name (Legal Business Name): KACEY JOHANNAH PRYZBY PNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2018
Last Update Date: 08/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

444 N SEA RD
SOUTHAMPTON NY
11968-2057
US

IV. Provider business mailing address

444 N SEA RD
SOUTHAMPTON NY
11968-2057
US

V. Phone/Fax

Practice location:
  • Phone: 631-283-4843
  • Fax:
Mailing address:
  • Phone: 631-283-4843
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number382897
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: