Healthcare Provider Details

I. General information

NPI: 1104750793
Provider Name (Legal Business Name): BERNADETTE C. DECARLO AGPCNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2026
Last Update Date: 06/21/2026
Certification Date: 06/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 NICOLLS RD
STONY BROOK NY
11794-0001
US

IV. Provider business mailing address

101 NICOLLS RD
STONY BROOK NY
11794-0001
US

V. Phone/Fax

Practice location:
  • Phone: 631-444-4000
  • Fax:
Mailing address:
  • Phone: 631-444-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number312852
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number312852
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number312852
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: